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................................. As the 10-year CVD risk thresholds guide treatment decisions and have an impact on healthcare costs and resources, countries or regions may decide on using higher or lower treatment thresholds.

3.2.3.4 Risk estimation and risk factor treatment in apparently healthy people 5069 years of age Stopping smoking, lifestyle recommendations, and SBP <160 mmHg are recommended for all (Figure 6). A 10-year CVD risk (fatal and nonfatal ASCVD events) >_10% is generally considered ‘very high risk’, and treatment of CVD risk factors is recommended. A 10-year CVD risk of 5 to <10% is considered ‘high risk’, and treatment of risk factors should be considered, taking CVD risk modifiers, lifetime risk and treatment benefit (in low- and moderate-risk regions, Box 1), and patient preferences into account. A 10-year CVD risk <5% is considered ‘low-to-moderate risk’, and would generally not qualify for risk factor treatment unless one or several risk modifiers (see section 3.3) increase risk, or the estimated lifetime risk and treatment benefit is considered substantial.

3.2.3.5 Risk estimation and risk factor treatment estimation in apparently healthy people 70 years of age Stop smoking, lifestyle recommendations and a SBP <160 mmHg are recommended for all (Figure 6). Age is the dominant driver of CVD

STEP 2 Patients with established ASCVDa

Stop smoking and lifestyle recommendations

(Class I)

LDL-C ≥50% reduction and <1.8 mmol/L (<70 mg/dL)

(Class I) SBP <140 to 130 mmHg

if tolerated (Class I)

Antithrombotic

Therapy (Class I)

AND

Residual 10-year CVD riskc Lifetime CVD risk and treatment benefitd Comorbidities, frailty Patient preferences

Intensified treatment based on:

STEP 1b

SBP <130 mmHg if tolerated (Class I) LDL-C <1.4 mmol/L

(<55 mg/dL)

(Class I) DAPT, DPI, novel upcoming

interventions (e.g. colchicine, EPA)

(Class IIb)

AND AND

Figure 7 Flow chart of cardiovascular risk and risk factor treatment in patients with established atherosclerotic cardiovascular disease. Ultimate treatment goals for SBP (<130 mmHg) and LDL-C (according to level of risk) according to the respective ESC Guidelines3,4 are to be pursued as indicated. The stepwise approach has to be applied as a whole: after STEP 1, considering proceeding to the intensified goals of STEP 2 is mandatory. ACS = acute coronary syndromes; ASCVD = atherosclerotic cardiovascular disease; CR = cardiac rehabilitation; CVD = cardiovascular disease; DAPT = dual antiplatelet therapy; DM = diabetes mellitus; ESC = European Society of Cardiology; EUROASPIRE = European Action on Secondary and Primary Prevention by Intervention to Reduce Events; LDL-C = low-density lipoprotein cholesterol; SBP = systolic blood pressure; SMART = Secondary Manifestations of Arterial Disease. Risk scores are available in the ESC CVD Risk Calculator app for mobile devices (https://www.escardio.org/Education/ESC-Preventionof-CVD-Programme/Risk-assessment/esc-cvd-risk-calculation-app) and at websites such as https://www.u-prevent.com. aFor patients with DM see DM flow chart (Figure 8). bFor patients with recent ACS, these prevention goals are part of participation in CR (Class I/A). cFor patients aged >_70 years, a high 10-year risk may be associated with a lower absolute lifetime benefit from treatment due to limited life expectancy. dLifetime treatment benefit is expressed as extra CVD-free life gained from a certain intervention or treatment intensification. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026