Cardiovascular risk prediction and when to treat — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 66-year-old man in Europe asks about statins and BP tablets. He has no established ASCVD, diabetes, chronic kidney disease, familial hypercholesterolaemia or hypertension-mediated organ damage. His office BP is 136/84 mmHg, confirmed out of office. His LDL-C is 3.2 mmol/L despite lifestyle changes. His 10-year SCORE2 risk is 9%.^[1][3][2]

1. Which ESC risk tool applies to him, and which ESC 2021 risk category is he in? (2)^[1]
2. Which ESC/EAS 2025 Table 3 category is he in, and what does the ESC/EAS 2025 row say about LDL-C-lowering therapy for him, with class and level? (3)^[2]
3. How does the ESC 2024 hypertension guideline classify his BP risk, and what treatment does it recommend? (2)^[3]
4. Name two ESC/EAS 2025 Box 1 risk modifiers and give the ESC/EAS 2025 row on CAC scoring, with class and level. (2)^[2]
5. Why do the ESC 2021 thresholds rise with age? (1)^[1]

Model answers — SAQ 1

1. SCORE2: recommended for 10-year fatal and non-fatal CVD risk in apparently healthy people younger than 70 years without established ASCVD, DM, CKD, or genetic/rarer lipid or BP disorders (ESC 2021, Class I, Level B) (1 mark).^[1] At 50–69 years, in apparently healthy people without DM, CKD, or genetic/rarer lipid or BP disorders, a SCORE2 of 5 to <10% is high risk, in which treatment of ASCVD risk factors should be considered, taking CVD risk modifiers, lifetime risk and treatment benefit, and patient preferences into account (ESC 2021, Class IIa, Level C) (1 mark).^[1]
2. ESC/EAS 2025 Table 3: a SCORE2 of ≥2% and <10% is moderate risk (1 mark).^[2] In primary prevention, pharmacological LDL-C-lowering therapy should be considered at moderate risk with LDL-C ≥2.6 mmol/L (100 mg/dL) but <4.9 mmol/L (190 mg/dL), despite optimisation of non-pharmacological measures, to lower CVD risk (1 mark), Class IIa, Level A (1 mark).^[2]
3. ESC 2024: his SCORE2 is below 10%, so he is not in the increased-risk group defined, irrespective of age, by a SCORE2 or SCORE2-OP risk of ≥10% (Class I, Level B) (1 mark).^[3] ESC 2024: with elevated BP and low/medium CVD risk (<10% over 10 years), BP lowering with lifestyle measures is recommended and can reduce the risk of CVD (Class I, Level B); ESC 2024 adds that high-risk ethnicity (e.g. South Asian), family history of premature-onset atherosclerotic CVD, socio-economic deprivation, auto-immune inflammatory disorders, HIV and severe mental illness are risk modifiers shared by both sexes that should be considered to up-classify individuals with elevated BP and borderline increased 10-year CVD risk (5% to <10%) (Class IIa, Level B) (1 mark).^[3]
4. Any two of: family history of premature CVD (men <55 years; women <60 years); high-risk ethnicity (e.g. Southern Asian); stress symptoms and psychosocial stressors; social deprivation; obesity; physical inactivity; chronic immune-mediated/inflammatory disorders; major psychiatric disorders; history of premature menopause; pre-eclampsia or other hypertensive disorders of pregnancy; HIV infection; obstructive sleep apnoea syndrome; persistently elevated hs-CRP (>2 mg/L); elevated Lp(a) [>50 mg/dL (>105 nmol/L)] (1 mark).^[2] Presence of subclinical coronary atherosclerosis by imaging or an increased CAC score by CT should be considered as risk modifiers in individuals at moderate risk or around treatment decision thresholds to improve risk classification (ESC/EAS 2025, Class IIa, Level B) (1 mark).^[2]
5. ESC 2021 sets numerically different cut-offs by age to avoid undertreatment in the young and overtreatment in older persons; age is a major driver of risk, but lifelong treatment benefit is higher in younger people (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 48-year-old woman in the United States has no ASCVD, no diabetes and no known subclinical atherosclerosis. Her LDL-C is 150 mg/dL (3.9 mmol/L) and she takes no lipid-lowering drug. She had pre-eclampsia in her only pregnancy. Her high-sensitivity C-reactive protein (hsCRP) was 3 mg/L on 2 successive occasions, with no identifiable underlying cause. Her 10-year PREVENT-ASCVD risk is 4%.^[4]

1. Which ACC/AHA 2026 risk category is she in, and name four inputs of the PREVENT base model. (2)^[4]
2. Give the ACC/AHA 2026 rows on risk enhancers and reproductive risk markers that apply to her, with COR and LOE. (2)^[4]
3. What does ACC/AHA 2026 say about her hsCRP result? (1)^[4]
4. If the decision remains uncertain, what do the ACC/AHA 2026 CAC rows say for her if the score is 0, and if it is >0? (2)^[4]
5. Why does ACC/AHA 2026 consider lipid-lowering therapy from a 10-year risk as low as 3%? (1)^[4]
6. Her 2018 letter gave a pooled cohort equation estimate of 7%. Explain the difference, with the crosswalk category. (2)^[4]

Model answers — SAQ 2

1. Borderline (3% to <5%): ACC/AHA 2026 says that in adults aged 30 to 79 years without ASCVD or subclinical atherosclerosis with LDL-C 70 to 189 mg/dL, the PREVENT-ASCVD equations should be used to estimate 10-year ASCVD risk and categorise it as low (<3%), borderline (3% to <5%), intermediate (5% to <10%) or high (≥10%) (COR 1, LOE B-NR) (1 mark).^[4] Any four of: age, sex, blood pressure, total and HDL cholesterol, diabetes status, tobacco use, eGFR, statin use and antihypertensive medication use (1 mark).^[4]
2. In adults without ASCVD with a borderline 10-year risk (3% to <5%), considering risk enhancers is reasonable to personalise risk assessment and the potential benefit of starting LLT as an adjunct to lifestyle management (COR 2a, LOE B-NR) (1 mark).^[4] In adults without ASCVD, considering reproductive risk markers such as early menopause (<45 years) and a history of adverse pregnancy outcomes (gestational hypertension, pre-eclampsia, gestational diabetes, preterm delivery) is reasonable to personalise ASCVD risk assessment when considering the potential benefit of initiating LLT as an adjunct to lifestyle management for primary ASCVD prevention (COR 2a, LOE B-NR) (1 mark).^[4]
3. With borderline risk, if hsCRP is measured and is ≥2 mg/L on 2 successive occasions with no identifiable underlying cause, high-intensity statin therapy can be useful to reduce the risk of ASCVD events (COR 2a, LOE B-R) (1 mark).^[4]
4. ACC/AHA 2026 Section 4.2.3.6 (men ≥40 or women ≥45 years), adults at intermediate risk or select adults at borderline risk who undergo CAC testing, with CAC 0 AU, a preference to avoid LLT and focus on lifestyle, and no higher-risk conditions (FH or severe hypercholesterolaemia >190 mg/dL, diabetes and age >40 years, current cigarette smoking, strong family history of premature ASCVD): it is reasonable to defer therapy and repeat CAC testing in 3 to 7 years (COR 2a, LOE B-NR) (1 mark).^[4] Same section, CAC >0 AU in intermediate or select borderline risk: initiating LLT is recommended, particularly if the score is ≥100 AU or ≥75th standardised percentile (COR 1, LOE B-NR) (1 mark).^[4]
5. Given the benefits of statins even at lower event rates and low rates of potential harms, a net benefit threshold as low as a predicted risk of 3% is now recommended for considering LLT; in primary prevention statin trials, net benefit was shown for moderate-intensity statin at an event rate of ≥3% in 10 years (1 mark).^[4]
6. PREVENT-ASCVD estimates are generally 40% to 50% lower than PCE estimates because the PCE often overestimated risk (1 mark).^[4] In the ACC/AHA 2026 Table 12 crosswalk, the PCE borderline range (5% to <7.5%) corresponds approximately to PREVENT-ASCVD 3% to <5% (1 mark).^[4]