ASCVD Risk Factors
The traditional ASCVD risk factors include age, sex, total cholesterol, HDL cholesterol, systolic blood pressure, antihypertensive medication use, diabetes mellitus, and current smoking status. 1
Traditional Risk Factors
The ACC/AHA guidelines identify the following as core traditional risk factors used in the Pooled Cohort Risk Equations 1:
- Age - the strongest contributor to 10-year predicted ASCVD risk 2
- Sex (male or female) 1
- Total cholesterol 1
- HDL cholesterol (low HDL-C: <40 mg/dL in men; <50 mg/dL in women) 1
- Systolic blood pressure 1
- Use of antihypertensive therapy 1
- Diabetes mellitus 1
- Current smoking 1
These risk factors should be measured and updated every 4-6 years to improve both short-term and long-term risk prediction 1.
Risk-Enhancing Factors
Beyond traditional risk factors, the 2019 ACC/AHA guidelines identify additional risk-enhancing factors that should be considered, particularly in patients at borderline (5% to <7.5%) or intermediate (≥7.5% to <20%) 10-year ASCVD risk. 1
Family and Demographic Factors
- Family history of premature ASCVD (males age <55 years; females age <65 years) 1
- High-risk race/ethnicity (e.g., South Asian ancestry) 1
Metabolic and Lipid Factors
- Primary hypercholesterolemia (LDL-C 160-189 mg/dL; non-HDL-C 190-219 mg/dL) 1
- Metabolic syndrome - requires 3 of the following: increased waist circumference (by ethnically appropriate cutpoints), elevated triglycerides (>150 mg/dL, nonfasting), elevated blood pressure, elevated glucose, and low HDL-C 1
- Persistently elevated primary hypertriglyceridemia (≥175 mg/dL, nonfasting) 1
Chronic Conditions
- Chronic kidney disease (eGFR 15-59 mL/min/1.73 m² with or without albuminuria; not treated with dialysis or kidney transplantation) 1
- Chronic inflammatory conditions such as psoriasis, rheumatoid arthritis, lupus, or HIV/AIDS 1
Women-Specific Risk Factors
- History of premature menopause (before age 40 years) 1
- History of pregnancy-associated conditions that increase later ASCVD risk, such as preeclampsia 1
Advanced Biomarkers (If Measured)
- Elevated high-sensitivity C-reactive protein (≥2.0 mg/L) 1
- Elevated Lp(a) - ≥50 mg/dL or ≥125 nmol/L, especially at higher levels; measurement particularly indicated with family history of premature ASCVD 1
- Elevated apoB (≥130 mg/dL) - measurement indicated when triglycerides ≥200 mg/dL; a level ≥130 mg/dL corresponds to LDL-C >160 mg/dL 1
- Ankle-brachial index <0.9 1
Modifiable Lifestyle Risk Factors
Cardiovascular risk factors should be systematically assessed at least annually in all patients. 1 Key modifiable factors include:
- Obesity/overweight 1
- Physical inactivity and sedentary behavior 3
- Poor dietary patterns 3
- Psychosocial stress 3
- Inadequate sleep (short sleep duration <6 hours and poor-quality sleep are associated with high blood pressure) 1
Clinical Considerations
The presence and severity of traditional ASCVD risk factors stratify absolute levels of lifetime risk. 1 For example, having ≥2 major risk factors (total cholesterol ≥240 mg/dL or treated, systolic BP ≥160 or diastolic BP ≥100 mm Hg or treated, diabetes, or current smoking) confers a lifetime ASCVD risk >50%, while all optimal levels of risk factors (untreated total cholesterol <180 mg/dL, untreated BP <120/80 mm Hg, no diabetes, and no current smoking) confer a lifetime risk <10% 1.
Risk factors measured in young and middle-aged adults are associated with short-term (≤10 years), long-term (≥15 years), and lifetime risk for ASCVD. 1 The strength of evidence is moderate for BMI, cholesterol, systolic BP, and smoking, and low for diabetes and metabolic syndrome 1.