ASCVD (Atherosclerotic Cardiovascular Disease) 2013 Risk Calculator from AHA/ACC

Why Use

The ASCVD Risk Estimate is a standardized guideline to predict risk and recommend management strategies for those at risk of hard ASCVD (i.e. myocardial infarction, stroke, or death due to coronary heart disease or stroke).

When to Use

Patients at risk for atherosclerotic cardiovascular disease (ASCVD).

Formula

Pearls / Pitfalls

In 2013 the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines for the evaluation and treatment of cholesterol in order to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). This calculator provides a simplified way to follow the ASCVD treatment recommendations for patients without known ASCVD and with LDL levels between 70-189 mg/dL (1.81-4.90 mmol/L). Our ASCVD Risk Algorithm is a step-wise approach for all adult patients – including those with known ASCVD. The treatment algorithm proposed by the ACC/AHA suggests aggressive treatment for many patients, but specifically notes that patients with known ASCVD and patients with extreme LDL levels (≥190 mg/dL / 4.92 mmol/L) are at the highest risk; it also provides the “intensity” of statin treatment based on patients' predicted risk levels. Points to keep in mind: While the score was developed and validated in a large population from the United States, several studies have suggested that the risk calculator substantially over-estimates 10-year risk, while other studies have suggested that its risk estimates are accurate. This score may not be generalizable to the global population. Statins are highly emphasized in the guidelines and recommendations, but lifestyle modifications are likely just as – if not more – important to ASCVD risk. Commonly referred to as the Pooled Cohort Equation (PCE). The PCE is not applicable to patients with atrial fibrillation or those older than 79 as they were excluded in the original derivation and validation study.

Advice

When Considering Starting Statins First, always engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug-drug interactions, and patient preferences. Consider: Potential for ASCVD risk-reduction benefits. Potential for adverse effects and drug-drug interactions. Heart-healthy lifestyle. Management of other risk factors. Patient preferences. See Section 5 of the relevant 2018 American guidelines for a discussion and recommendations about statin safety. Also see Table 3 of the same guidelines for summary of grossly equivalent statin intensities for different statins at different doses. When Considering or Using High-Intensity Statins The guidelines recommend the treating clinician consider: Multiple or serious comorbidities, such as impaired renal or hepatic function. A history of previous statin intolerance or muscle disorders. Unexplained elevated levels of alanine transaminase greater than three times the upper limit of normal. Patient characteristics or concomitant use of medications that affect statin metabolism. Age older than 75 years. Remember that the risk of statin-related adverse effects are generally intensity-dependent. Additional Factors that are ASCVD Risk Enhancers per 2018 American Guidelines Family history of premature ASCVD. Persistently elevated LDL-C levels at or above 160 mg/dL (4.1 mmol/L). Chronic kidney disease. Metabolic syndrome. Conditions specific to women (e.g. preeclampsia, premature menopause). Inflammatory diseases (especially rheumatoid arthritis, psoriasis, HIV). Ethnicity (e.g. South Asian ethnicity). Persistently elevated triglycerides levels at or above 175 mg/dL (2.0 mmol/L). And in selected individuals if measured: High-sensitivity C-reactive protein (hsCRP) levels at or above 2.0 mg/L. Lp(a) levels above 50 mg/dL (125 nmol/L). ApoB at or above 130 mg/dL. Ankle-brachial index <0.9. When Monitoring Statin Effects and Side Effects Assess adherence, response to therapy, and adverse effects within 4 to 12 weeks following statin initiation or change in therapy. Measure fasting lipid levels. Do not routinely monitor alanine transaminase or creatine kinase levels unless symptomatic. Screen and treat type 2 diabetes according to current practice guidelines; heart-healthy lifestyle habits should be encouraged to prevent progression to diabetes.

More Information

These estimates may underestimate the 10-year risk for some race/ethnic groups, including American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans). It may overestimate the risk for some Asian Americans (e.g., of east Asian ancestry) and some Hispanics (e.g., Mexican Americans). Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results. Optimal Risk Factors For the comparison of optimal risk factors, these were defined by the following specific risk factor numbers for an individual of the same age, sex and race: Total cholesterol of 170 mg/dL. HDL-cholesterol of 50 mg/dL. Untreated systolic blood pressure of 110 mm Hg. No diabetes history. Not a current smoker. US Preventive Services Task Force (USPSTF) Guidelines In 2016, the US Preventive Services Task Force (USPSTF) made similar but slightly different recommendations for adults without a history of cardiovascular disease (CVD) to use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: Age 40 to 75 years. 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking). Calculated 10-year risk of a cardiovascular event of 10% or greater (B recommendation). The USPSTF gave a B recommendation—indicating high certainty that the benefit is moderate or moderate certainty that the benefit is moderate to substantial—for starting low- to moderate-dose statins in adults ages 40 to 75 years without a history of cardiovascular disease (CVD) who have one or more CVD risk factors and a 10-year CVD risk of 10% or greater. The USPSTF dropped its level of endorsement to C for adults with a lower 10-year risk (7.5%-10%) and made no recommendations for adults 76 years of age and older, explaining that there was insufficient evidence for this age group. These recommendations have been maintained in the 2022 version . *Thanks to Vijay Shetty, MBBS, for this summary of the 2016 USPSTF guidelines. Intensity of Statin Therapy Type of Statin Taken Daily, Average LDL Lowering Effect Types of Medication High-intensity statin therapy Approximately ≥50% Atorvastatin 40–80 mg Rosuvastatin 20-40 mg Moderate-intensity statin therapy Approximately 30% to <50% Atorvastatin 10-20 mg Rosuvastatin 5-10 mg Simvastatin 20–40 mg Pravastatin 40-80 mg Lovastatin 40 mg Fluvastatin XL 80 mg Fluvastatin 40 mg BID Pitavastatin 2–4 mg Low-intensity statin therapy Approximately <30% Simvastatin 10 mg Pravastatin 10–20 mg Lovastatin 20 mg Fluvastatin 20–40 mg Pitavastatin 1 mg