2013 ACC/AHA 10-year atherosclerotic cardiovascular disease risk.

What it is and when to use it

The ASCVD 10-year Risk (Pooled Cohort Equations) estimates the 10-year probability of a first atherosclerotic cardiovascular disease event (non-fatal myocardial infarction, coronary death, or fatal/non-fatal stroke) in adults without established cardiovascular disease. It combines age, sex, race, total and HDL cholesterol, systolic blood pressure (treated or untreated), smoking, diabetes, and antihypertensive treatment. The equations were derived by the ACC/AHA in the 2013 guideline, and their decision thresholds were reaffirmed in the 2018 ACC/AHA cholesterol and 2019 primary-prevention guidelines to guide initiation of statin therapy.

How to interpret it

The result is stratified into four 10-year risk bands: low (<5%), borderline (5% to <7.5%), intermediate (7.5% to <20%), and high (>=20%). In intermediate risk (7.5% to <20%), a moderate-intensity statin is recommended after a risk-benefit discussion; in high risk (>=20%), high-intensity statin therapy is recommended. In the borderline band (5% to <7.5%), a moderate-intensity statin is considered when risk-enhancing factors are present. These factors (premature family history, lipoprotein(a), C-reactive protein, ankle-brachial index) and the coronary artery calcium (CAC) score help refine the decision and personalize the risk-benefit discussion with the patient.

Limitations and when not to use it

The equations are validated in adults aged 40 to 79 without prior cardiovascular disease, derived from US white and African-American cohorts; they tend to overestimate risk in contemporary, European, and other ethnic populations (Asian, Hispanic). They do not apply to secondary prevention, to LDL >=190 mg/dL, and do not replace clinical judgment. They do not assess short-term or lifetime risk, and are not validated outside the age range or in patients with already known cardiovascular disease.

Frequently asked questions

What is the difference between the ASCVD score and the European SCORE2?

Both estimate 10-year cardiovascular risk in primary prevention, but the ASCVD is the ACC/AHA tool derived from a US population, whereas SCORE2 is the tool recommended by the ESC guideline and is calibrated to European risk regions.

At what percentage should a statin be started?

The ACC/AHA guideline recommends a moderate-intensity statin in intermediate risk (7.5% to <20%) and a high-intensity statin when risk is >=20%; between 5 and <7.5% (borderline risk) the decision is individualized using risk-enhancing factors, always within shared decision-making with the patient.

Can the ASCVD score be used if the patient has already had a heart attack?

No; the Pooled Cohort Equations are for primary prevention only. A patient with established cardiovascular disease is already high-risk and requires intensive treatment regardless of the calculated score.