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...................................... Social deprivation and psychosocial stress set the scene for increased risk.13 For those at moderate risk, other factors—including metabolic factors such as increased ApoB, lipoprotein(a) [Lp(a)], triglycerides (TGs), or C-reactive protein; the presence of albuminuria; the presence of atherosclerotic plaque in the carotid or femoral arteries; or the coronary artery calcium (CAC) score—may improve risk classification. Many other biomarkers are also associated with increased CVD risk, although few of these have been shown to be associated with appreciable reclassification. Total CV risk will also be higher than indicated in the SCORE charts in asymptomatic persons with abnormal markers of subclinical atherosclerotic vascular damage. Reclassification is of value in people identified as being at moderate CV risk by using markers such as CAC score >100 Agatston units, anklebrachial index (ABI) <0.9 or >1.40, carotidfemoral pulse wave velocity >10 m/s, or the presence of plaques at carotid or femoral ultrasonography. In studies comparing these markers, CAC had the best reclassification ability.1416

Some factors such as a high HDL-C up to 2.3 mmol/L (90mg/dL)17 or a family history of longevity can also be associated with lower risk.

4.2 Risk levels

A total CV risk estimate is part of a continuum. The cut-off points that are used to define high-risk are, in part, both arbitrary and based on the risk levels at which benefit is evident in clinical trials. In clinical practice, consideration should be given to practical issues in relation to the local healthcare systems. Not only should those at high risk be identified and managed, but those at moderate risk should also receive professional advice regarding lifestyle changes; in some cases, drug therapy will be needed to reduce atherosclerotic risk. Low-risk people should be given advice to help them maintain this status. Thus, the intensity of preventive actions should be tailored to the patient’s total CV risk. The strongest driver of total CV risk is age, which can be considered as ‘exposure time’ to risk factors.

For these reasons, the Task Force suggests the following categories of risk and LDL-C goals, based on the best available evidence and in an ideal setting with unlimited resources. These categories represent a counsel of perfection, but these ideals are for guidance only and practical decision-making must be based on what is appropriate to the local situation. With these considerations, we propose the levels of total CV risk presented in Table 4.

Box 5 Risk estimation: key messages

In apparently healthy persons, CVD risk is most frequently the result of multiple, interacting risk factors. This is the basis for total CV risk estimation and management. Risk factor screening including the lipid profile should be considered in men >40 years old, and in women >50 years of age or post-menopausal. A risk estimation system such as SCORE can assist in making logical management decisions, and may help to avoid both under- and overtreatment. Certain individuals declare themselves to be at high or very high CVD risk without needing risk scoring, and all risk factors require immediate attention. This is true for patients with documented CVD, older individuals with longstanding DM, familial hypercholesterolaemia, chronic kidney disease, carotid or femoral plaques, coronary artery calcium score >100, or extreme Lp(a) elevation. All risk estimation systems are relatively crude and require attention to qualifying statements. Additional factors affecting risk can be accommodated in electronic risk estimation systems such as HeartScore (www.heartscore.org). The total risk approach allows flexibility; if optimal control cannot be achieved with one risk factor, trying harder with the other factors can still reduce risk. CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; SCORE = Systematic Coronary Risk Estimation. Table 4 Cardiovascular risk categories

Very-highrisk People with any of the following: Documented ASCVD, either clinical or unequivocal

on imaging. Documented ASCVD includes previous ACS (MI or unstable angina), stable angina, coronary revascularization (PCI, CABG, and other arterial revascularization procedures), stroke and TIA, and peripheral arterial disease. Unequivocally documented ASCVD on imaging includes those findings that are known to be predictive of clinical events, such as significant plaque on coronary angiography or CT scan (multivessel coronary disease with two major epicardial arteries having >50% stenosis), or on carotid ultrasound. DM with target organ damage,a or at least three major

risk factors, or early onset of T1DM of long duration (>20 years). Severe CKD (eGFR <30 mL/min/1.73 m2). A calculated SCORE >_10% for 10-year risk of fatal CVD. FH with ASCVD or with another major risk factor.

High-risk People with:

Markedly elevated single risk factors, in particular TC

>8 mmol/L (>310 mg/dL), LDL-C >4.9 mmol/L (>190 mg/dL), or BP >_180/110 mmHg. Patients with FH without other major risk factors. Patients with DM without target organ damage,a with DM

duration >_10 years or another additional risk factor. Moderate CKD (eGFR 3059 mL/min/1.73 m2). A calculated SCORE >_5% and <10% for 10-year risk

of fatal CVD.

Moderate-risk Young patients (T1DM <35 years; T2DM <50 years)

with DM duration <10 years, without other risk factors. Calculated SCORE >_1 % and <5% for 10-year risk of fatal CVD.

Low-risk Calculated SCORE <1% for 10-year risk of fatal CVD. ASCVD = atherosclerotic cardiovascular disease; ACS = acute coronary syndrome; BP = blood pressure; CABG = coronary artery bypass graft surgery; CKD = chronic kidney disease; CT = computed tomography; CVD = cardiovascular disease; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; FH = familial hypercholesterolaemia; LDL-C = low-density lipoprotein cholesterol; MI = myocardial infarction; PCI = percutaneous coronary intervention; SCORE = Systematic Coronary Risk Estimation; T1DM = type 1 DM; T2DM = type 2 DM; TC = total cholesterol; TIA = transient ischaemic attack. aTarget organ damage is defined as microalbuminuria, retinopathy, or neuropathy. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026