ASCVD Risk

The Pooled Cohort Equations (PCE) estimate 10-year risk of a first atherosclerotic cardiovascular event (MI or stroke). Variables include age, sex, race, total cholesterol, HDL, systolic BP, blood pressure treatment, diabetes status, and smoking. The equations were derived from multiple large US cohorts including ARIC, CHS, CARDIA, and Framingham. Note: the AHA PREVENT equations (Khan, Circulation 2024) are a newer, race-free alternative that starts at age 30, adds BMI, eGFR and statin use, reports 30-year as well as 10-year risk, and estimates heart failure separately; they are better calibrated and usually estimate lower risk than the PCE. They are on this site at /calculators/prevent. The familiar 5 / 7.5 / 20% statin thresholds below were set against the PCE, which is why this tool keeps them and the PREVENT tool reports absolute risk without categories.

CAC scoring is most useful for intermediate-risk patients (7.5-19.9%) where the statin decision is uncertain, or borderline-risk patients (5-7.4%) with risk enhancers. A CAC of 0 generally favors deferring statin therapy (except in smokers, diabetics, and those with strong family history). CAC >= 100 or >= 75th percentile for age/sex/race favors statin initiation.

(1) Clinical ASCVD (secondary prevention): high-intensity statin, LDL goal <70. (2) LDL >= 190 mg/dL (e.g., familial hypercholesterolemia): high-intensity statin without needing risk calculation. (3) Diabetes, age 40-75: at least moderate-intensity statin. (4) Primary prevention, age 40-75, with 10-year ASCVD risk >= 7.5%: moderate-to-high-intensity statin based on risk discussion.