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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 September 10, 2019 e603 CLINICAL STATEMENTS AND GUIDELINES IIb B-NR 5. For adults 20 to 39 years of age and for those 40 to 59 years of age who have <7.5% 10-year ASCVD risk, estimating lifetime or 30-year ASCVD risk may be considered.S2.2-1,S2.2-2,S2.2-32–S2.2-35 Synopsis Assessment of ASCVD risk remains the foundation of primary prevention. Although all individuals should be encouraged to follow a heart-healthy lifestyle, estimating an individual’s 10-year absolute ASCVD risk enables matching the intensity of preventive interventions to the patient’s absolute risk, to maximize anticipated benefit and minimize potential harm from overtreatment. The 10-year ASCVD risk estimate is used to guide decisionmaking for many preventive interventions, including lipid managementS2.2-4,S2.2-36 and BP management;S2.2-37 it should be the start of a conversation with the patient about risk-reducing strategies (the “clinician–patient discussion”) and not the sole decision factor for the initiation of pharmacotherapy.S2.2-4,S2.2-36,S2.2-38 All risk estimation tools have inherent limitations, and population-based risk scores must be interpreted in light of specific circumstances for individual patients. The PCE have been shown to overestimateS2.2-15,S2.2-39–S2.2-47 or underestimateS2.2-12,S2.2-48–S2.2-51 ASCVD risk for certain subgroups. Thus, after calculation of the PCE, it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions for borderline- or intermediate-risk adults.S2.2-4–S2.2-14 However, the value of preventive therapy may remain uncertain for many individuals with borderline or intermediate estimated 10-year risk, and some patients may be reluctant to take medical therapy without clearer evidence of increased ASCVD risk. For these individuals, the assessment of coronary artery calcium is a reasonable tool to reclassify risk either upward or downward, as part of shared decision-making. For younger adults 20 to 59 years of age, estimation of lifetime risk may be considered. For adults >75 years of age, the clinician and patient should engage in a discussion about the possible benefits of preventive therapies appropriate to the age group in the context of comorbidities and life expectancy. Recommendation-Specific Supportive Text 1 To facilitate decisions about preventive interven- tions, it is recommended to screen for traditional ASCVD risk factors and apply the race- and sexspecific PCE (ASCVD Risk Estimator) to estimate 10-year ASCVD risk for asymptomatic adults 40 to 75 years of age.S2.2.1,S2.2.2 For management of stage 1 hypertension (BP 130–139 / 80–89 mm Hg), adults should be categorized as <10% or >10% 10-year ASCVD risk for therapeutic decisions (see Section 4.4 Figure 4). For management of blood cholesterol, adults should be categorized as having low (<5%), borderline (5% to <7.5%), intermediate (≥7.5% to <20%), or high (≥20%) 10-year risk.S2.2-4 The PCE are best validated among non- Hispanic whites and non-Hispanic blacks living in the United States.S2.2-1,S2.2-39,S2.2-48,S2.2-49,S2.2-52 In other racial/ethnic groupsS2.2-53,S2.2-54 or in some non- US populations,S2.2-40,S2.2-41,S2.2-53,S2.2-54 the PCE may overestimate or underestimate risk. Therefore, clinicians may consider the use of another risk prediction tool as an alternative to the PCE if the tool was validated in a population with characteristics similar to those of the evaluated patient. Examples include the general Framingham CVD risk score,S2.2-55 the Reynolds risk scores,S2.2-56,S2.2-57 SCORE (Systematic COronary Risk Evaluation),S2.2-58 and the QRISK/JBS3S2.2-59 tools. Other professional societies have incorporated some of these alternative validated risk scores into their lipid management guidelines or have considered different risk thresholds for preventive interventions.S2.2-58–S2.2-63 Although slight differences exist across organizational guidelines, they are all very similar in their overarching goal of matching the intensity of preventive therapies to the absolute (generally 10-year) risk of the patient.S2.2-58–S2.2-63 2 After age 20 years, it is reasonable to mea- sure traditional risk factors at least every 4 to 6 years.S2.2-1,S2.2-3 For adults 20 to 39 years of age, limited data exist on the performance and utility of 10-year risk estimation tools.S2.2-64 Because age is a major driver of risk, most in this age range (<40 years) are unlikely to have a sufficiently elevated 10-year risk to warrant pharmacological therapy with a statin (with some exceptions, such as in familial hypercholesterolemia). Nevertheless, periodic assessment of risk factors (eg, at least every 4 to 6 years in younger adults 20 to 39 years of age) is important to guide discussions about intensity of lifestyle interventions, frequency of risk factor monitoring, treatment of nonlipid risk factors, and consideration of 30-year or lifetime risk estimation.S2.2-1–S2.2-3 3 No single risk calculator is appropriate for all patients. In certain populations, the PCE have reasonable calibration.S2.2-1,S2.2-65–S2.2-67 However, some studies have found underestimation of risk (and potential for undertreatment) among individuals with chronic inflammatory conditions (eg, autoimmune disease,S2.2-50 HIV infectionS2.2-12) or socioeconomic disadvantageS2.2-48,S2.2-49,S2.2-51 not Recommendations for Assessment of Cardiovascular Risk (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026