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.......................................................................... categories of CVD risk (‘low-to-moderate’, ‘high’, and ‘very high’). The cut-off risk levels for these categories are numerically different for various age groups to avoid undertreatment in the young and to avoid overtreatment in older persons. As age is a major driver of CVD risk, but lifelong risk factor treatment benefit is higher in younger people, the risk thresholds for considering treatment are lower for younger people (Table 5).

Risk categories do not ‘automatically’ translate into recommendations for starting drug treatment. In all age groups, consideration of risk modifiers, lifetime CVD risk, treatment benefit, comorbidities, frailty, and patient preferences may further guide treatment decisions. Also, note that many patients can move themselves towards a lower risk category without taking drugs just by stopping smoking. Finally, note that persons >_70 years old may be at very high risk whilst being at target SBP, and primary prevention with lipid-lowering drugs in older persons is a Class IIb (‘may consider’) recommendation; see section 4.6. In the 5069-year age range, a 10-year CVD mortality risk threshold of 5% estimated with the previously used SCORE algorithm corresponds, on average, to a 10-year fatal and non-fatal CVD risk threshold of 10% estimated with SCORE2, as approximately the same number of people are above the risk threshold and would qualify for treatment.68

Table 5 Cardiovascular disease risk categories based on SCORE2 and SCORE2-OP in apparently healthy people according to age

<50 years 5069

years 70 yearsa

Low-to-moderate CVD risk: risk factor treatment generally not recommended <2.5% <5% <7.5% High CVD risk: risk factor treatment should be considered 2.5 to <7.5% 5 to <10% 7.5 to <15% Very high CVD risk: risk factor treatment generally recommendeda >_7.5% >_10% >_15% CVD = cardiovascular disease. aIn apparently healthy people >_70 years old, the treatment recommendation for lipid-lowering drugs is Class IIb (‘may be considered’). The division of the population into three distinct age groups (<50, 5069, and >_70 years) results in a discontinuous increase in risk thresholds for low-to-moderate, high, and very high risk. In reality, age is obviously continuous, and a sensible application of the thresholds in clinical practice would require some flexibility in handling these risk thresholds as patients move towards the next age group, or recently passed the age cut-off. Figure 5 illustrates how a continuous increase in age relates to increasing risk thresholds, and may be used as a guide for daily practice. ESC 2021

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25 22.5 20 17.5 15 12.5 10 7.5 5 2.5

40 50 60 70 80 90

Age groups (years)

50-69 <50 ≥70

10-year CVD risk (%)

CVD risk thresholds (%)

Very high CVD risk

High CVD risk

Low-to-moderate CVD risk

Figure 5 Schematic representation of increasing 10-year cardiovascular disease risk thresholds across age groups. CVD = atherosclerotic cardiovascular disease. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026