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....................................................... A stepwise approach starts with prevention goals for all, regardless of CVD risk. This is followed by CVD risk stratification and discussion of potential benefits of treatment with the patient. If treatment is initiated, its effect must be evaluated, and subsequent treatment intensification to reach ultimate risk factor goals must be considered in all patients, taking into account additional benefit, comorbidities, and frailty, all of which converge with patient preferences in a shared decision-making process.

In the field of DM, studies have shown benefit of a stepwise approach to treatment intensification and do not support the contention of ‘therapeutic nihilism’ occurring in either physicians or patients. In fact, it appears that attainment of treatment goals is similar, sideeffects are fewer, and patient satisfaction is significantly higher with such an approach.66,67 We do, however, emphasize that stopping assessment of treatment goals and/or treatment routinely after the first step is inappropriate. The evidence-based ultimate targets of treatment intensification are optimal from the perspective of CVD risk reduction and are to be considered in all patients. 3.2.3.2 Risk estimation in apparently healthy people Apparently healthy people are those without established ASCVD, type 2 DM, or severe comorbidities. In the 2016 ESC prevention guidelines,2 the Systemic Coronary Risk Estimation (SCORE) algorithm was used to estimate 10-year risk of CVD death. However, CVD morbidity (non-fatal myocardial infarction, non-fatal stroke) combined with CVD mortality better reflects the total burden of ASCVD. The updated SCORE algorithm—SCORE2—used in these guidelines (see Figure 3), estimates an individual’s 10-year risk of fatal and non-fatal CVD events (myocardial infarction, stroke) in apparently healthy people aged 4069 years with risk factors that are untreated or have been stable for several years.68

Several specific considerations apply to CVD risk estimation in older people. First, the gradient of the relationship between classical risk factors, such as lipids and BP, with CVD risk attenuates with age.69 Second, CVD-free survival dissociates from overall survival progressively with increasing age, because risk for non-CVD mortality increases (‘competing risk’).70 For these reasons, traditional risk

Categories of individuals considered for prevention

STEP 1

10-year CVD risk Lifetime CVD risk and treatment benefit Comorbidities Patient preferences

Intensified prevention and treatment goals based on:

Apparently healthy

persons (See Figure 6)

STEP 2 Patients with established ASCVD

(See Figure 7) Patients with type 2 diabetes mellitus

(See Figure 8) Patients with specific risk

factors such as CKD and FH (See Table 4)

Prevention goals for all Prevention goals for all Prevention goals for all

Specific risk factor prevention and treatment goals based on risk categories

Estimate 10-year

CVD risk

Consider risk modifiers, lifetime CVD risk, treatment benefit and patient preferences

Prevention goals

Ultimate prevention goals Prevention goals based on whether patients are

without or with established ASCVD and/or severe TOD

10-year CVD risk Lifetime CVD risk and treatment benefit Comorbidities Patient preferences

Intensified prevention and treatment goals based on:

Ultimate prevention goals 10-year CVD risk Lifetime CVD risk and treatment benefit Comorbidities Patient preferences

Intensified prevention and treatment goals based on:

Ultimate prevention goals

Figure 2 Examples of a stepwise approach to risk stratification and treatment options. ASCVD = atherosclerotic cardiovascular disease; CKD = chronic kidney disease; DM = diabetes mellitus; FH = familial hypercholesterolaemia; TOD = target organ damage. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026