What is Atherosclerotic Cardiovascular Disease (ASCVD)?
ASCVD is a clinical diagnosis encompassing acute coronary syndrome, history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, and peripheral artery disease—all presumed to be of atherosclerotic origin. 1, 2
Clinical Definition and Scope
ASCVD represents the manifestation of atherosclerotic plaque formation and progression throughout the arterial system, leading to clinically significant cardiovascular events. 1 The definition specifically includes:
Coronary manifestations: Acute coronary syndromes, myocardial infarction (both prior and acute), stable angina, unstable angina, and any coronary revascularization procedures 1, 2
Cerebrovascular manifestations: Both ischemic stroke and transient ischemic attack 1, 2
Peripheral vascular manifestations: Peripheral artery disease and aortic aneurysm, when presumed atherosclerotic in origin 1, 2
Other arterial revascularization: Any arterial revascularization procedure outside the coronary circulation 1, 2
Why This Broad Definition Matters Clinically
The comprehensive definition ensures that all patients with established atherosclerotic disease in any vascular bed receive identical intensive secondary prevention strategies, regardless of which territory initially manifested disease. 2 A patient with peripheral artery disease carries the same ASCVD designation and warrants the same treatment intensity as someone with prior myocardial infarction. 2
This unified approach is critical because atherosclerosis is a systemic disease process—plaque formation in one vascular bed indicates widespread atherosclerotic burden and elevated risk for events in all territories. 1
Epidemiological Significance
ASCVD remains the leading cause of death and disability globally, despite improvements in awareness and treatment. 1, 3 In the United States specifically, ASCVD is the leading cause of sudden cardiac death and acute myocardial infarction in adults, particularly those over age 35-40 years. 1
The disease develops over decades through cumulative exposure to causal risk factors, with atherosclerotic plaque formation beginning long before clinical manifestations appear. 1 This prolonged subclinical phase underscores the importance of early risk assessment and primordial prevention. 1
Risk Assessment Context
For patients without clinical ASCVD, the term is used to define the outcome being predicted in risk calculators. 1 The 10-year ASCVD risk specifically refers to the probability of nonfatal myocardial infarction, coronary heart disease death, or nonfatal and fatal stroke. 1
For patients with established clinical ASCVD, risk estimation tools are not appropriate—these patients automatically qualify for the most intensive preventive therapies regardless of calculated risk scores. 1
Critical Pitfall to Avoid
Never exclude patients with peripheral or cerebrovascular manifestations from the ASCVD category. 2 A common error is treating coronary disease as the only "true" ASCVD requiring aggressive secondary prevention, while undertreating patients whose atherosclerosis first manifested as stroke or claudication. 2 All ASCVD patients warrant high-intensity statin therapy (or maximum tolerated intensity), antiplatelet therapy, blood pressure control, and comprehensive risk factor management. 1, 2
Distinction from Risk Factors
ASCVD itself is the disease manifestation, not the risk factors that cause it. 1 Risk-enhancing factors that increase ASCVD probability include family history of premature ASCVD, metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, elevated lipid biomarkers, and high-risk ethnicity—but these are contributors to ASCVD development, not ASCVD itself. 1