What is the approach to determining the cardiovascular disease (CVD) risk score for adult patients with risk factors like hypertension, diabetes, or high cholesterol?

Cardiovascular Disease Risk Score Assessment

For adults aged 40-79 years without established CVD, use the ACC/AHA Pooled Cohort Equations to calculate 10-year ASCVD risk; for European populations or those aged ≥70 years, use SCORE2 (ages 40-69) or SCORE2-OP (ages ≥70) instead. 1, 2

Primary Risk Assessment Tools by Population

United States: ACC/AHA Pooled Cohort Equations

• The ACC/AHA Pooled Cohort Equations are the recommended tool for adults aged 40-79 years, incorporating age, sex, race (non-Hispanic White or African American), total cholesterol, HDL cholesterol, systolic blood pressure, hypertension treatment status, diabetes, and smoking status 1, 3
• This calculator estimates 10-year risk of hard ASCVD events including nonfatal MI, CHD death, and fatal or nonfatal stroke 1
• Risk stratification thresholds: ≥10% defines higher risk requiring treatment consideration; 7.5-10% represents intermediate risk requiring shared decision-making 1, 3

European Populations: SCORE2 and SCORE2-OP

• SCORE2 is recommended for individuals aged 40-69 years to assess 10-year risk of fatal and non-fatal CVD 2
• SCORE2-OP is recommended for individuals aged ≥70 years as it better calibrates risk in older adults 2
• A 10-year CVD risk ≥10% defines "increased risk" warranting treatment, irrespective of age 2
• SCORE2-Diabetes should be considered for type 2 diabetes patients with elevated blood pressure, particularly if <60 years of age 2

Patients Who Don't Need Risk Calculators

Certain high-risk conditions automatically place patients at increased CVD risk without requiring formal risk calculation: 2, 3

• Established CVD (coronary artery disease, cerebrovascular disease, peripheral arterial disease, heart failure)
• Moderate or severe chronic kidney disease (CKD stages 3-5)
• Diabetes mellitus (particularly type 1 or longstanding type 2)
• Familial hypercholesterolemia
• Hypertension-mediated organ damage (HMOD)
• Grade 3 hypertension (≥180/110 mmHg)

These patients are already at sufficiently high risk to warrant intensive preventive therapy without calculation. 2, 3

Age-Specific Considerations

Younger Adults (<40 years)

• For adults <40 years, calculate lifetime CVD risk rather than 10-year risk, as 10-year estimates are universally low and misleading in this age group 1, 3, 2

Older Adults (≥76 years)

• Evidence is insufficient to guide risk assessment and treatment decisions in adults ≥76 years 1
• However, the 2024 ESC guidelines recommend SCORE2-OP for all adults ≥70 years, suggesting continued risk assessment in this population 2

Risk Refinement Beyond Basic Calculators

When to Consider Additional Risk Modifiers

For patients with borderline or intermediate risk (5-10% 10-year risk), additional risk-enhancing factors can refine assessment and guide treatment decisions: 1, 3, 2

• Family history of premature ASCVD (men <55 years, women <65 years) 2, 1
• Chronic inflammatory conditions (rheumatoid arthritis, psoriasis, HIV) 1
• South Asian ancestry 1
• Metabolic syndrome 4
• Chronic kidney disease (eGFR 45-59 mL/min/1.73 m²) 2
• History of preeclampsia or gestational hypertension in women 2
• Premature menopause (<40 years) 2

Coronary Artery Calcium (CAC) Scoring

• CAC scoring can help guide treatment decisions for intermediate-risk patients or selected borderline-risk patients when uncertainty remains after initial risk assessment 1, 3

Common Pitfalls and Caveats

Age Dominates Risk Calculations

• Age heavily influences calculated risk: 41% of men and 27% of women aged 60-69 years without CVD have calculated 10-year risk ≥10% even without traditional risk factors 1
• This can lead to overtreatment based solely on age rather than modifiable risk factors 2

Risk Overestimation

• The Pooled Cohort Equations have been criticized for overestimating risk when applied to contemporary US cohorts, particularly at lower risk levels 1
• Consider this when making treatment decisions for patients with borderline risk scores 1

Predictive Performance

• Most multivariable risk equations yield ROC areas of approximately 0.80, indicating relatively high but imperfect discrimination 2, 5
• Family history modestly improves risk stratification (C statistic increases from 0.82 to 0.83) but has limited positive predictive value (28-66%) 2

Reassessment Intervals

Periodic reassessment is essential for accurate risk management: 1

• Blood pressure: annually
• Lipid levels: every 5 years
• Smoking status: annually
• Complete risk recalculation: every 5 years or when risk factors change 2

Clinical Context

Among US adults with hypertension, multiple risk factors commonly coexist: 2

• 49.5% are obese
• 63.2% have hypercholesterolemia
• 27.2% have diabetes
• 15.8% have chronic kidney disease
• 41.7% have 10-year CHD risk >20%

This clustering of risk factors results in high absolute CVD risk, making systematic risk assessment critical for appropriate preventive therapy intensity. 2, 6