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.................................................................................................. risk, and estimated 10-year CVD risk of almost all individuals >_70 years exceeds conventional risk thresholds. Also, lifetime benefit of treatment in terms of time gained free of CVD is lower in older people. Therefore, the CVD risk thresholds for risk factor treatment are higher in apparently healthy people >_70 years. A 10-year CVD risk >15% is generally considered ‘very high risk’, and treatment of ASCVD risk factors is recommended (note: the recommendation for lipid-lowering treatment in apparently healthy people >_70 years is class IIb; ‘may be considered’; see section 4.6). A 10-year CVD risk of 7.5 to <15% is considered ‘high risk’, and treatment of risk factors should be considered taking CVD risk modifiers, frailty, lifetime treatment benefit (in low and moderate risk regions, Box 1), comorbidities, polypharmacy, and patient preferences into account. Given the subjective nature of many of these factors, it is not possible to define strict criteria for these considerations. A 10-year CVD risk <7.5% is considered ‘low-to-moderate risk’, and would generally not qualify for risk factor treatment unless one or several risk modifiers (section 3.3) increase risk or the estimated lifetime risk and treatment benefit is considered substantial.7579

3.2.3.6 Risk estimation and risk factor treatment in apparently healthy people <50 years of age Stopping smoking, lifestyle recommendations, and SBP <160 mmHg are recommended for all (Figure 6). The 10-year CVD risk in relatively young, apparently healthy people is on average low, even in the presence of high risk factor levels, but the lifetime CVD risk is in these circumstances very high. In apparently healthy people <50 years of age, a 10-year CVD risk >_7.5% is generally considered ‘very high risk’ as this risk relates to a high lifetime risk, and treatment of ASCVD risk factors is recommended. A 10-year CVD risk of 2.5 to <7.5% 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), and patient preferences into account. A 10year CVD risk <2.5% 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 (see Box 1) (Figure 6).7578

In risk communication with younger people, the lifetime benefit perspective may be useful, as well as discussing the potential of avoiding a devastating CVD event in the short-to-intermediate term, despite the fact that 10-year CVD risk may be very low. CVD risk predictions, as well as predictions of lifetime benefit of risk factor treatment, are likely to be imprecise at very young age (<40 years). At that age, lipid-lowering and BP-lowering drug treatment are not usually considered, except for patients with FH or specific BP disorders. A healthy lifestyle that is maintained throughout life is more relevant for the very young. Mendelian randomization studies illustrate very nicely that relatively small differences in LDL-C or SBP maintained throughout life have large implications on CVD risk over a lifespan.80

3.2.3.7 Risk estimation and risk factor treatment in patients with established atherosclerotic cardiovascular disease Patients with clinically established ASCVD are, on average, at very high risk of recurrent CVD events if risk factors are not treated. Therefore, smoking cessation, adoption of a healthy lifestyle, and risk factor treatment is recommended in all patients (STEP 1). Further intensification of risk factor treatment by aiming at lower treatment goals (STEP 2) is beneficial in most patients and must be considered, taking 10-year CVD risk, comorbidities, lifetime risk and treatment benefit (Box 1), frailty, and patient preferences into account in a shared decision-making process (Figure 7). After initial risk factor treatment and the achievement of risk factor treatment goals, the individual residual risk for recurrent

Box 1. Lifetime CVD risk and treatment benefit estimation

Prevention of CVD by treating risk factors is usually done with a lifetime perspective. Lifetime CVD risk can be approximated by clinical experience with clinical criteria such as age, (change in) risk factor levels, risk modifiers, etc. or estimated in apparently healthy people, patients with established ASCVD, and persons with type 2 DM with specific lifetime CVD risk scores.7577 Lifetime benefit from risk factor management can be estimated by combining lifetime risk models with HRs derived from RCTs, meta-analyses of RCTs, or Mendelian randomization studies, which may provide estimates of the effects of longer-term treatment of risk factors. Online calculators (such as the ESC CVD Risk app) can be used to estimate the average lifetime benefit of smoking cessation (see also Figure 11), lipid lowering (see also Figure 12), and BP lowering (see also Figure 15) on an individual patient level expressed as extra CVD-free life-years.78 Average lifetime benefit is easy to interpret and may improve the communication of potential therapy benefits to patients in a shared decision-making process. This may in turn increase patient engagement, self-efficacy, and motivation to adhere to lifestyle changes and drug treatment. The lifetime risk is an estimate of the age at which there is a 50% probability that a person will either have experienced a CVD event or have died. Lifetime benefit is the numerical difference between the predicted age at which there is a 50% probability that a person will either have experienced a CVD event or have died with and without a proposed treatment. Currently there are no formal treatment thresholds for average lifetime benefit. In addition, the estimated individual lifetime benefit should be viewed in the light of the estimated duration of treatment. Duration of lifelong treatment will generally be longer in young persons compared to older people. Both treatment effect and treatment duration determine the individual ‘return on investment’ of risk factor treatment. In a shared decision-making process between healthcare provider and patient, the minimum desired benefit of a certain treatment needs to be established, a process in which patient preference, expected treatment harms, and costs can be taken into account. BP = blood pressure; CVD = cardiovascular disease; DM = diabetes mellitus; ESC = European Society of Cardiology; HR = hazard ratio; RCT = randomized controlled trial. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026