Atherosclerotic cardiovascular disease, or ASCVD, is caused by the buildup of plaque inside blood vessels1. ASCVD is an umbrella term that is used to refer to conditions such as coronary heart disease, cerebrovascular disease, peripheral artery disease, and aortic atherosclerotic disease. ASCVD-related conditions are the leading causes of morbidity and mortality across the globe2. Due to the high rates of poor outcomes associated with heart diseases, a great deal of attention is placed on the prevention of ASCVD.
Assessing ASCVD risk
Assessing ASCVD risk is the basis of primary prevention and can be used as an effective tool to guide preventative decisions, whether it be medication or lifestyle changes. The American College of Cardiology and American Heart Association recommend using ASCVD risk estimators to determine an individual’s risk for developing ASCVD in 10-years, 30-years, or lifetime depending on individual factors. The resulting percentages are classified into categories as shown below:
- Low: <5%
- Borderline: 5 – <7.5%
- Intermediate: ≥7.5 to <20%
- High: ≥20%
For people who are age 20-39, it is reasonable to measure risk factors every 4-6 years to identify major risk factors such as tobacco use, dyslipidemia, family history of ASCVD, chronic inflammatory diseases, hypertension, and type-2 diabetes1.
Estimating 10-year ASCVD risk can be used to determine if preventative interventions are warranted, and how intense these therapies should be. Assessments of 10-year risk are usually recommended for adults who are 40-75 years old, or for those who are 20-39 years old and have risk enhancing factors.
Estimating 30-year or lifetime risks can be a useful communication strategy for providers to encourage healthy lifestyle changes and medication adherence to further reduce the possibility of developing complications. This type of assessment is usually performed for those who are not at a high short-term risk of developing ASCVD. People who are age 20-39 and for those who are 40-59 who do not have a 10-year risk of >7.5% may be a candidate for such an assessment3.
Statins
Plaque buildup is usually the result of high cholesterol, and a lot of focus in the prevention of ASCVD is placed on cholesterol lowering therapies. Reductions in LDL-C are associated with reduction in ASCVD outcomes. Statins are regularly prescribed medications for high cholesterol disorders and are commonly used in primary prevention. The ACC recommends addition of statin therapy in the following cases1:
- Age 20-75 with LDL-C≥190 mg/dl
- Treatment with a high intensity statin without risk assessment is warranted.
- Age 40-75 with a diagnosis of Type-2 Diabetes
- Treatment with a moderate intensity statin is recommended, and individual risk assessments should be conducted to consider high intensity statin therapy.
- Age 40-75 with LDL-C≥70 mg/dl and <190mg/dl, without a diagnosis of Type-2 Diabetes.
- Conduct an individual risk assessment
- Risk 5% to <7.5% (borderline risk)
- If risk-enhancing factors are present, Discuss moderate-intensity statins
- Risk ≥7.5-20% (intermediate risk)
- Treatment with moderate-intensity statins, and increase to high-intensity with risk enhancers
- Risk ≥20% (high risk)
- Clinician-patient risk discussion should take place to decide whether to use high-intensity Statins or other methods of ASCVD prevention
- Risk 5% to <7.5% (borderline risk)
- Conduct an individual risk assessment
Statin Dosages 4
| Low-Intensity Statin Dosages | Moderate-Intensity Statin Dosages | High-Intensity Statin Dosages |
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Sources
Arnett D, Blumenthal R, Albert M, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. J Am Coll Cardiol. 2019 Sep, 74 (10) e177–e232.https://doi.org/10.1016/j.jacc.2019.03.010
American Heart Association. (n.d.). ASCVD. www.heart.org. Retrieved March 9, 2023, from https://www.heart.org/en/professional/quality-improvement/ascvd
Lloyd-Jones, D. M., Braun, L. T., Ndumele, C. E., Smith, S. C., Sperling, L. S., Virani, S. S., & Blumenthal, R. S. (2019). Use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease: A special report from the American Heart Association and American College of Cardiology. Circulation, 139(25). https://doi.org/10.1161/cir.0000000000000638
Chou R, Cantor A, Dana T, et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Aug. (Evidence Synthesis, No. 219.) Table 1, Statin Dosing and ACC/AHA Classification of Intensity. Available from: https://www.ncbi.nlm.nih.gov/books/NBK583664/table/ch1.tab1/
