# ASCVD Risk Calculator

## Pooled cohort risk predicts 10-year risk for a first atherosclerotic cardiovascular disease (ASCVD) event

### Risk Factors for ASCVD

 Gender Male Female Age years Race White or other African American Total Cholesterol mg/dL mmol/L HDL Cholesterol mg/dL mmol/L
 Systolic BP mmHg Receiving treatment for high blood pressure (if SBP > 120 mmHg) No Yes Diabetes No Yes Smoker No Yes

RESULTS

#### ASCVD Risk Evaluation

 10-year risk of atherosclerotic cardiovascular disease: 16.6% 10-year risk in a similar patient with optimal risk factors : 3.6%
 Lifetime risk of atherosclerotic cardiovascular disease : 50%(95% CI 46% to 55%) Lifetime risk for a 50-year-old with optimal risk factors : 5%(95% CI 0% to 12%)

#### ASCVD Risk Interpretation 1,2

Statin recommendations based on ASCVD risk is intended for patients age 40-75 years
with LDL-C 70 to < 190 mg/dL (1.8 to < 4.9 mmol/L) without diabetes mellitus
Low Risk
(< 5%)
Borderline Risk
(5% to < 7.5%)
Intermediate Risk
(≥ 7.5% to < 20%)
High Risk
(≥ 20%)
Emphasize healthy lifestyle factors to reduce risk factors (class I) Consider moderate-intensity statin if risk-enhancing factors are present (class IIb) Consider moderate-intensity statin if risk-enhancing factors are present (class I) Consider high-intensity statin (class I)
Risk-enhancing factors are a variety of factors known to increase future ASCVD risk but are not necessarily captured within the ASCVD calculation. Clinicians should use judgment when evaluating whether risk-enhancing factors favors statin initiation or not; there is no number of risk-enhancing factors that must be met to prompt statin initiation. These risk factors could include: family history of premature ASCVD, metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, etc.2
• This patient is at intermediate 10-year risk (7.5% to < 20%) for atherosclerotic cardiovascular disease (ASCVD)
• For patients 40-74 years old with diabetes, a moderate intensity statin can be considered regardless of ASCVD risk. In patients with multiple risk factors, it is reasonable to use high-intensity statin therapy to reduce LDL-C by ≥ 50%

This peer-reviewed online calculator uses the Pooled Cohort Equations to estimate the 10-year primary risk of ASCVD (atherosclerotic cardiovascular disease) among patients without pre-existing cardiovascular disease who are between 40 and 79 years of age.1 Patients are considered to be at "elevated" risk if the Pooled Cohort Equations predicted risk is ≥ 7.5% (possibly ≥ 5%). In many ways, the Pooled Cohort Equations have been proposed to replace the Framingham Risk 10-year CVD calculation, which was recommended for use in the NCEP ATP III guidelines for high blood cholesterol in adults.3

Current guidelines for the treatment of cholesterol to reduce cardiovascular risk recommend that the following four groups of patients will benefit from moderate- or high-intensity statin therapy:2

• Individuals with clinical ASCVD
• Individuals with primary elevations of LDL ≥ 190 mg/dL
• Individuals 40 to 75 years of age with diabetes and an LDL 70 to 189 mg/dL without clinical ASCVD
• Individuals without clinical ASCVD or diabetes who are 40 to 75 years of age with LDL 70 to 189 mg/dL and a 10-year ASCVD risk of 5-7.5% or higher

As shown above, among patients who do not otherwise have a compelling indication for statin therapy, the Pooled Cohort Equations can be used to estimate primary cardiovascular risk and potential benefit from statin therapy.

#### What is ASCVD?

ASCVD stands for atherosclerotic cardiovascular disease, defined as a nonfatal myocardial infarction (heart attack), coronary heart disease death, or stroke. The purpose of the Pooled Cohort Equations is to estimate the risk of ASCVD within a 10-year period among patients who have never had one of these events in the past.

#### Impact of Race on the Pooled Cohort Equations

The Pooled Cohort Equations were developed and validated among Caucasian and African American men and women who did not have clinical ASCVD. There are inadequate data in other racial groups, such as Hispanics, Asians, and American-Indian populations. Given the lack of data, current guidelines suggest to use the "Caucasian" race to estimate 10-year ASCVD risk with the knowledge that further research is needed to stratify these patients' risk. Compared to Caucasians, the risk of ASCVD is generally lower among Hispanic and Asian populations and generally higher among American-Indian populations.

#### Statin Regimens

The 2019 ACC/AHA guidelines recommend either a high-intensity or moderate-intensity statin regimen in patients who have an elevated ASCVD risk (≥ 5-7.5%) for primary prevention of cardiovascular disease. The recommended doses for each of these regimens are shown below:

High-Intensity
(>50% LDL-C Reduction)
Moderate-Intensity
(30% to 50% LDL-C Reduction)
Low-Intensity
(<30% LDL-C Reduction)
Atorvastatin 40 to 80 mg 10 to 20 mg
Rosuvastatin 20 to 40 mg 5 to 10 mg
Simvastatin 20 to 40 mg 10 mg
Fluvastatin 40 mg BID / 80 mg XL 20 to 40 mg
Lovastatin 40 to 80 mg 20 mg
Pitavastatin 1 to 4 mg
Pravastatin 40 to 80 mg 10 to 20 mg
Citations: (1) Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25):e1082‐e1143. doi:10.1161/CIR.0000000000000625. (2) Chou R, Dana T, Blazina I, et al. Statin Use for the Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Nov. (Evidence Syntheses, No. 139.) Table 1, Statin Dosing and ACC/AHA Classification of Intensity. Available from: https://www.ncbi.nlm.nih.gov/books/NBK396417/table/ch1.t1/

#### How was the Pooled Cohort Equations Model Developed?

The Pooled Cohort Risk Assessment Equations was developed by the Risk Assessment Work Group, an arm of the ACC/AHA Cardiovascular Risk Guidelines, to identify appropriate candidates for statin therapy based on elevated cardiovascular risk.1 Statistical modeling to create a new risk assessment tool was developed using a variety of participants from several large, diverse NHLBI-sponsored studies.

#### Lifetime ASCVD Risk

In individuals aged 20 to 59 years of age, a lifetime risk assessment is mentioned by guidelines (with a 'low' strength of evidence).1 A long-term risk assessment may be more accurate in younger individuals free from ASCVD (eg, 20 to 59 years old). This lifetime estimation was based on a paper published in 2006 that was developed by assigning a patient into one of five mutually exclusive sex-specific groups.4 In some cases, the 10-year ASCVD risk may be higher than lifetime risk due to differing mathematical approaches. If this is the case, the 10-year risk should be the primary focus for risk identification.

1. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. doi: 10.1161/​01.cir.0000437741.48606.98.
2. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646. PMID 30879355.
3. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001 May 16;285(19):2486-97. PMID 11368702.
4. Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006 Feb 14;113(6):791-8. PMID 16461820.