How to Assess 10-Year Cardiovascular Risk
Use the ACC/AHA Pooled Cohort Equations calculator for all adults aged 40-79 years to estimate 10-year atherosclerotic cardiovascular disease (ASCVD) risk, which is the most validated and guideline-endorsed tool for U.S. populations. 1, 2
Required Input Variables
The calculator requires nine specific parameters 2:
- Age (40-79 years)
- Sex (male or female)
- Race (non-Hispanic White or non-Hispanic African American)
- Total cholesterol (mg/dL)
- HDL cholesterol (mg/dL)
- Systolic blood pressure (mmHg)
- Antihypertensive treatment status (yes/no)
- Diabetes mellitus (yes/no)
- Current smoking status (yes/no)
Risk Categorization
The calculated 10-year ASCVD risk stratifies patients into actionable categories 2, 3:
- Low risk: <5%
- Borderline risk: 5-7.4%
- Intermediate risk: 7.5-19.9%
- High risk: ≥20%
For treatment decisions, the critical threshold is ≥10% 10-year risk, which defines higher-risk patients who benefit from statin therapy. 4, 1
When to Assess Risk
Cardiovascular risk factors should be systematically assessed at least annually in all patients 4. Specific reassessment intervals include 2:
- Blood pressure: annually
- Lipid levels: every 5 years
- Smoking status: annually
Risk-Enhancing Factors for Borderline/Intermediate Risk
For patients with 7.5-10% risk who are uncertain about treatment, consider these risk-enhancing factors 1, 2:
- Family history of premature ASCVD (men <55 years, women <65 years)
- LDL-C ≥160 mg/dL
- Metabolic syndrome
- Chronic kidney disease
- History of preeclampsia or premature menopause (women)
- Chronic inflammatory disorders (rheumatoid arthritis, psoriasis, HIV)
- South Asian ancestry
- Persistently elevated triglycerides (>175 mg/dL)
- Elevated high-sensitivity C-reactive protein (≥2 mg/L)
- Elevated lipoprotein(a) (>50 mg/dL)
- Reduced ankle-brachial index (<0.9)
Coronary Artery Calcium (CAC) Scoring for Uncertain Cases
For intermediate-risk patients (7.5-19.9%) uncertain about statin benefit, CAC scoring is the most accurate additional tool to refine risk assessment. 1, 3
CAC score interpretation 1:
- CAC = 0: Consider withholding or delaying statin therapy
- CAC 1-99: Favors statin therapy
- CAC ≥100 or ≥75th percentile: Strongly indicates statin therapy
Automatic High-Risk Categories (No Calculator Needed)
Patients with existing CVD are automatically considered high risk and do not require risk calculation 4:
- History of myocardial infarction or stroke
- Chronic kidney disease stages 3-5
- Type 1 or type 2 diabetes with complications (albuminuria, retinopathy)
- Age ≥65 years with hypertension
Critical Caveats
Age heavily influences calculated risk—41% of men and 27% of women aged 60-69 years have calculated risk ≥10% even without other traditional risk factors. 1, 2 This means older patients may cross treatment thresholds based primarily on age alone.
The Pooled Cohort Equations may overestimate risk in contemporary populations, particularly at the lower end of the risk spectrum. 1, 5 Recent data suggest that applying these equations could result in treatment recommendations for patients at lower actual risk than intended.
Do not use the Pooled Cohort Equations for patients <40 or >79 years, as they were not validated in these age groups. 3 For younger adults (<40 years), calculate lifetime CVD risk instead to avoid false reassurance from low short-term risk estimates. 4, 2
The calculator only includes non-Hispanic White and African American populations. 2 For other racial/ethnic groups, apply the equations with caution and consider ethnicity-specific risk factors (e.g., South Asian ancestry increases risk). 1
Access the Calculator
The ACC/AHA ASCVD Risk Estimator Plus is available online at tools.acc.org/ASCVD-Risk-Estimator-Plus 4, 2