Does the Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment determine both the Hypertension (HTN) medication regimen and the cholesterol medication regimen, or only the cholesterol medication regimen?

ASCVD Risk Assessment and Medication Decisions

ASCVD risk assessment determines both hypertension medication regimens AND cholesterol medication regimens, but in different ways and for different patient populations.

How ASCVD Risk Guides Hypertension Treatment

For patients with Stage 1 hypertension (130-139/80-89 mmHg), ASCVD risk assessment directly determines whether antihypertensive medication is initiated. 1

Stage 1 HTN Treatment Algorithm:

• High-risk Stage 1 HTN (medication recommended) is defined by ANY of the following: 1

  • PCE-estimated 10-year ASCVD risk ≥10%
  • Diabetes mellitus
  • Estimated GFR <60 mL/min per 1.73 m²
  • Age ≥65 years with systolic BP ≥130 mmHg

• Low-risk Stage 1 HTN (medication NOT recommended) is defined by the absence of ALL the above risk factors 1

• Stage 2 HTN (≥140/90 mmHg) receives medication regardless of ASCVD risk 1

Clinical Significance:

The 2017 ACC/AHA guidelines explicitly incorporate the pooled cohort equation (PCE) 10-year ASCVD risk ≥10% threshold as one of four criteria that converts low-risk Stage 1 HTN into high-risk Stage 1 HTN requiring medication. 1 This means approximately one-third of patients with elevated BP or Stage 1 HTN who would otherwise not receive medication may be reclassified to treatment based on their ASCVD risk score. 1

How ASCVD Risk Guides Cholesterol Treatment

For primary prevention of ASCVD, the 10-year risk calculation is THE central determinant for statin initiation in patients without diabetes and LDL-C 70-189 mg/dL. 1

Statin Benefit Groups:

The 2013 ACC/AHA cholesterol guidelines identify four major statin benefit groups, with ASCVD risk assessment determining treatment in one specific group: 1

1. Secondary prevention (clinical ASCVD present) - statin indicated regardless of risk calculation 1
2. Primary LDL-C ≥190 mg/dL - statin indicated regardless of risk calculation 1
3. Diabetes, age 40-75, LDL-C 70-189 mg/dL - statin indicated regardless of risk calculation 1
4. Primary prevention, no diabetes, age 40-75, LDL-C 70-189 mg/dL with 10-year ASCVD risk ≥7.5% - statin indicated based on risk calculation 1

Risk-Based Statin Intensity:

• ≥7.5% 10-year ASCVD risk: Moderate- to high-intensity statin recommended 1
• 5% to <7.5% 10-year ASCVD risk: Moderate evidence supports statin use; requires clinician-patient discussion 1
• <5% 10-year ASCVD risk: Selected individuals may benefit; requires detailed discussion 1

Key Algorithmic Differences

For Hypertension:

The ASCVD risk threshold is ≥10% and serves as ONE of FOUR criteria (along with diabetes, CKD, or age ≥65) to determine medication initiation specifically in Stage 1 HTN. 1 It does NOT determine the choice of antihypertensive agent or target BP, only whether to treat at all in this borderline BP range.

For Cholesterol:

The ASCVD risk threshold is ≥7.5% and serves as THE PRIMARY criterion for statin initiation in the specific population without diabetes or severely elevated LDL-C. 1 It also guides statin intensity selection.

Risk-Enhancing Factors for Uncertain Decisions

When the risk-based treatment decision is uncertain (particularly for cholesterol management near the 7.5% threshold or HTN near the 10% threshold), additional factors may be considered: 1

• Family history of premature ASCVD (<55 years in male first-degree relative, <65 years in female first-degree relative) 1
• High-sensitivity C-reactive protein ≥2 mg/L 1
• Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity 1
• Ankle-brachial index <0.9 1
• Elevated lifetime ASCVD risk 1
• Cardiac biomarkers (hs-cTnT ≥6 ng/L or NT-proBNP ≥100 pg/mL) may improve risk stratification for HTN treatment decisions 1

Critical Clinical Pitfalls

Do not confuse the different risk thresholds: The 10% threshold applies to HTN medication decisions in Stage 1 HTN, while the 7.5% threshold applies to statin decisions in primary prevention without diabetes. 1

Do not use ASCVD risk calculation in patients who already meet criteria for treatment: Patients with clinical ASCVD, LDL-C ≥190 mg/dL, diabetes (for statins), or Stage 2 HTN (for BP medication) should receive treatment regardless of calculated risk. 1

Do not ignore that ASCVD risk assessment uses the Pooled Cohort Equations: This specific calculator must be used for guideline-concordant risk estimation, as it defines the populations studied and the risk thresholds recommended. 1