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Intensification of risk factor treatment in STEP 2 must be considered in all patients, taking into account 10-year CVD risk, comorbidities, lifetime risk and treatment benefit (Box 1), frailty, and patient preferences in a shared decision-making process.75

3.2.3.9 Risk estimation and risk factor treatment in persons with type 1 diabetes mellitus People with type 1 DM are at increased CVD risk, and earlier manifestation of type 1 DM relates to more life-years lost in women than men, mostly due to CVD.91 RRs of CVD are, on average, higher in type 1 vs. type 2 DM, due to an average of three to four extra decades of hyperglycaemia, and usual risk factors contribute strongly to CVD outcomes in type 1 DM.92 CVD risks have declined over time, commensurate with improvements in life expectancy.93 Lifetime CVD risks in type 1 DM are higher with poorer glycaemic control, lower social class, and younger age of onset. The absolute risk of CVD events or CVD mortality is highest among those with any evidence of microvascular disease, particularly renal complications, and is strongly influenced by age. CVD risk stratification in persons with type 1 DM may be based on the same risk classification as for type 2 DM, summarized in Table 4, although the level of evidence for type 1 DM is weaker.

3.2.4. Communication of cardiovascular disease risk Reducing CVD risk at the individual level begins with appropriate assessment of individual risk and effective communication of risk and anticipated risk reduction by risk factor treatment. Patient-doctor interactions are complex and communicating risk is challenging.94,95 There is no single ‘correct’ approach; rather, it will depend on the individual’s preferences and understanding, which may differ with education status and numeracy. Risk perception is also strongly affected by emotional factors such as fear, optimism, etc. (‘patients don’t think risk, they feel risk’).96 It is important to explore whether patients understand their risk, the anticipated risk reduction, and the pros and cons of intervention, and to identify what is important to them. For example, one patient may focus on living free of medications, whereas another may be less able to change their lifestyle. In terms of outcomes, reducing mortality risk is crucial to some, whereas disease risk is more important to others. Short-term risk may motivate some patients, whereas lifetime benefit (see Box 1) will have more impact in others. In general, visual aids (graphs etc.) improve risk understanding, absolute risk (reduction) is better understood than RR (reduction), and the use of ‘numbers needed to treat’ is less well understood. In apparently healthy people, the standard approach is to report absolute 10-year risk of a CVD event with SCORE2 or SCORE2-OP, which can be found at the ESC CVD Risk Calculator app (https:// www.escardio.org/Education/ESC-Prevention-of-CVD-Programme/ Risk-assessment/esc-cvd-risk-calculation-app) or at http:// www.heartscore.org or https://www.u-prevent.com. In specific situations, one may opt for expressing risk in terms other than absolute 10-year risk. Examples of such situations include risks in young or very old people. In young people, lifetime risk might be more informative, as 10-year CVD risk is usually low even in the presence of risk factors. In older persons, specific risk estimation is required, taking competing non-CVD mortality into account.78 Direct translation of RRs to treatment decisions is not recommended, as absolute risk remains the key criterion for starting treatment.

An alternative way of expressing individual risk is to calculate a person’s ‘risk age’.96 The risk age of a person with several ASCVD risk factors is the age of a person of the same sex with the same level of risk but with low levels of risk factors. Risk age is an intuitive and easily understood way of illustrating the likely reduction in life expectancy that a young person with a low absolute but high RR of CVD will be exposed to if preventive measures are not adopted. Risk age is also automatically calculated as part of HeartScore (http://www.heartscore.org/).9799 CVD risk may also be expressed with a lifetime rather than a 10year horizon, for example, the LIFE-CVD (LIFEtime-perspective CardioVascular Disease) calculator (ESC CVD Risk Calculation app or https://www.u-prevent.com) (also see Box 1).78 Lifetime CVD risk-prediction models identify high-risk individuals both in the short and long term. Such models account for predicted risk in the context of competing risks from other diseases over the remaining expected lifespan of an individual. A similar approach also employing lifetime perspective is to calculate lifetime benefit of preventive

Recommendation for CVD risk communication

Recommendation Classa Levelb

An informed discussion about CVD risk and treatment benefits tailored to the needs of a patient is recommended.96 I C

CVD = cardiovascular disease. aClass of recommendation. bLevel of evidence.

Recommendations for CVD risk modifiers

Recommendations Classa Levelb

Stress symptoms and psychosocial stressors modify CVD risk. Assessment of these stressors should be considered.100102 IIa B CAC scoring may be considered to improve risk classification around treatment decision thresholds. Plaque detection by carotid ultrasound is an alternative when CAC scoring is unavailable or not feasible.103,104 IIb B Multiplication of calculated risk by RR for specific ethnic subgroups should be considered.105 IIa B The routine collection of other potential modifiers, such as genetic risk scores, circulating or urinary biomarkers, or vascular tests or imaging methods (other than CAC scoring or carotid ultrasound for plaque determination), is not recommended. III B

CVD = cardiovascular disease; CAC = coronary artery calcium; RR = relative risk. aClass of recommendation. bLevel of evidence. ESC 2021 ESC 2021

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