Cardio · prevention-risk
Cardiovascular risk prediction and when to treat: SCORE2, PREVENT and the Australian calculator
Fellowship-level guide to cardiovascular risk estimation in primary prevention under the 2021 ESC prevention guideline, the 2025 ESC/EAS dyslipidaemia focused update, the 2024 ESC hypertension guideline, the 2026 ACC/AHA dyslipidemia guideline, the 2025 AHA/ACC high blood pressure guideline and the 2023 Australian guideline: who to assess, SCORE2, SCORE2-OP, SCORE2-Diabetes, PREVENT and the Aus CVD Risk Calculator, risk categories and thresholds by age, risk modifiers and enhancers, coronary artery calcium scoring, the risk triggers for lipid and BP treatment, and how the scores differ.
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Red flags
- The SCORE2 charts do not apply to people with documented CVD or other high-risk conditions such as DM, FH, other genetic or rare lipid or BP disorders or CKD, or in pregnancy (ESC 2021); in type 2 DM without symptomatic ASCVD or severe target organ damage, ESC 2023 recommends estimating 10-year CVD risk via SCORE2-Diabetes (Class I, Level B), which refers to patients aged ≥40 years
- ESC 2021 thresholds depend on age: in apparently healthy people without DM, CKD, or genetic/rarer lipid or BP disorders, very high risk is a SCORE2 of ≥7.5% under 50 years, ≥10% at 50–69 years and a SCORE2-OP of ≥15% at 70 years or older
- PREVENT-ASCVD estimates generally run 40% to 50% lower than pooled cohort equation (PCE) estimates for the same profile, and ACC/AHA 2026 pairs them with newer, lower thresholds: its Table 12 crosswalk gives PCE intermediate 7.5% to <20% as approximately PREVENT-ASCVD 5% to <10%
- ACC/AHA 2026: deferring statins in intermediate- or lower-risk adults with CAC=0 is reasonable, but important exceptions include FH or severe hypercholesterolaemia >190 mg/dL, diabetes, current tobacco use and a strong family history of premature ASCVD
- The Aus CVD Risk Calculator gives 5-year risk; its 10% high-risk cut-off is not the same as a 10-year 10% under ESC/EAS 2025 Table 3 or ACC/AHA 2026
This page covers the step before much preventive prescribing. It asks how likely an apparently healthy person is to have a cardiovascular event, and whether that risk is high enough to treat.[2][4]
- LDL-C goals and drug choice: Dyslipidaemia: LDL-C targets, statin intensity, ezetimibe and PCSK9 inhibitors.
- BP measurement and staging: Hypertension: diagnosis and staging.
- Drug therapy once coronary disease is established: Chronic coronary syndrome: antianginal therapy, event prevention and where revascularisation fits.
Why estimate risk at all
ESC/EAS 2025 gives a worked example, assuming an average 20% relative reduction in risk per mmol/L lower LDL-C.[2] Lowering LDL-C by 1 mmol/L would cut a 20% absolute risk to 16%, a 4% absolute reduction.[2] The same fall would cut a 10% absolute risk only to 8%, a 2% absolute reduction.[2] The same LDL-C fall buys twice the absolute benefit in the higher-risk person, which is why the decision starts with risk.[2]
ESC/EAS 2025 states the aim directly.[2] Estimating risk identifies individuals at elevated risk who may benefit from interventions to lower LDL-C and other modifiable causes of ASCVD.[2]
ACC/AHA 2026 continues to recommend quantitative absolute risk estimation, for most individuals, to assist the benefit-risk discussion around starting lipid-lowering therapy (LLT) in primary prevention.[4] Absolute risk estimation allows direct comparison of potential benefits and harms, so that the expected net clinical benefit of LLT can be individualised and quantified.[4]
Who should be assessed, and who skips the calculator
ESC 2021 defines apparently healthy people as those without established ASCVD, type 2 DM or severe comorbidities.[1]
ESC 2021: who to assess (selected rows)
| ESC 2021 row (Recommendations for CVD risk assessment) | Class, Level |
|---|---|
| Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor (family history of premature CVD, familial hypercholesterolaemia (FH), CVD risk factors such as smoking, arterial hypertension, DM, raised lipid level, obesity, or comorbidities increasing CVD risk) | I, C |
| Systematic or opportunistic CV risk assessment in the general population in men >40 years and in women >50 years or postmenopausal with no known ASCVD risk factors may be considered | IIb, C |
| After CVD risk assessment in the context of opportunistic screening, a repetition of screening after 5 years (or sooner if risk was close to treatment thresholds) may be considered | IIb, C |
| Systematic CVD risk assessment in men <40 years and women <50 years with no known CV risk factors is not recommended | III, C |
Australia sets assessment by age band, with earlier starts for people with diabetes and for First Nations people.[6] The 2023 Australian guideline recommends assessment in all people aged 45–79 years without known CVD.[6] It starts at 35 years in people with diabetes and at 30 years in First Nations people.[6]
People already at high risk without a score
Under ESC 2021, the SCORE2 charts are the wrong tool once a high-risk condition is present.[1]
- ESC 2021 (Class I, Level A): patients with established ASCVD and/or DM and/or moderate-to-severe renal disease and/or genetic/rarer lipid or BP disorders are to be considered at high or very high CVD risk.[1]
- ESC 2021: the SCORE2 charts do not apply to persons with documented CVD or other high-risk conditions such as DM, FH, or other genetic or rare lipid or BP disorders, CKD, and in pregnant women.[1]
- Type 2 DM (ESC 2023, newer than ESC 2021): in patients with type 2 DM without symptomatic ASCVD or severe target organ damage, the diabetes guideline instead recommends estimating 10-year CVD risk via SCORE2-Diabetes (Class I, Level B), with categories from low to very high (see below).[10]
- Its footnote says SCORE2-Diabetes refers to patients aged ≥40 years; below 40 years, risk factors for ASCVD should be evaluated on an individual basis.[10]
- Severe TOD in that row (ESC 2023 footnote): eGFR <45 mL/min/1.73 m² irrespective of albuminuria; or eGFR 45–59 mL/min/1.73 m² and microalbuminuria (UACR 30–300 mg/g; stage A2); or proteinuria (UACR >300 mg/g; stage A3); or microvascular disease in at least three different sites (e.g. microalbuminuria (stage A2) plus retinopathy plus neuropathy).[10]
- Heterozygous FH (ACC/AHA 2026, COR 3: Harm, LOE C-EO): standard risk assessment tools developed for the general population should not be used to calculate 10- or 30-year ASCVD risk.[4]
ESC/EAS 2025 Table 3 (Cardiovascular risk categories): conditions that set the category
| ESC/EAS 2025 Table 3 category | Conditions (other than a calculated score) |
|---|---|
| Very high risk | Documented ASCVD, either clinical or unequivocal on imaging (documented ASCVD includes previous ACS (MI or unstable angina), chronic coronary syndromes, coronary revascularisation (PCI, CABG and other arterial revascularisation procedures), stroke and TIA, and peripheral arterial disease); DM with target organ damage, or at least three major risk factors, or early onset of type 1 DM of long duration (>20 years); severe CKD (eGFR <30 mL/min/1.73 m²); FH with ASCVD or with another major risk factor |
| High risk | Markedly elevated single risk factors, in particular total cholesterol >8 mmol/L (>310 mg/dL), LDL-C >4.9 mmol/L (>190 mg/dL), or BP ≥180/110 mmHg; FH without other major risk factors; DM without target organ damage, with DM duration ≥10 years or another additional risk factor; moderate CKD (eGFR 30–59 mL/min/1.73 m²) |
| Moderate risk | Young patients (type 1 DM <35 years; type 2 DM <50 years) with DM duration <10 years, without other risk factors |
- Target organ damage (ESC/EAS 2025 Table 3 footnote): defined as microalbuminuria, retinopathy, or neuropathy.[2]
- Imaging counts (ESC/EAS 2025 Table 3): unequivocally documented ASCVD on imaging includes findings known to predict clinical events, such as significant plaque on coronary angiography or CT, on carotid or femoral ultrasound, or a markedly elevated CAC score by CT; the footnotes give significant plaque as typically >50% stenosis and a markedly elevated CAC score as, for example, >300.[2]
- BP decisions (ESC 2024, Class I, Level B): a risk-based approach to elevated BP is recommended, and people with moderate or severe CKD, established CVD, hypertension-mediated organ damage (HMOD), diabetes or FH are considered at increased risk for CVD events.[3]
- Lipid decisions (ACC/AHA 2026, Figure 6 footnote): severe hypercholesterolaemia (LDL-C ≥190 mg/dL), diabetes, subclinical coronary atherosclerosis, CKD stage 3 or higher and HIV have their own sections of the guideline.[4]
The scores
SCORE2: Europe, 40 to 69 years
ESC 2021 explains why SCORE was replaced.[1] The 2016 ESC prevention guideline used the SCORE algorithm, which estimated 10-year risk of CVD death.[1] CVD morbidity (non-fatal MI, non-fatal stroke) combined with CVD mortality better reflects the total burden of ASCVD.[1] SCORE2 therefore estimates 10-year risk of fatal and non-fatal CVD events (MI, stroke).[1] It applies to apparently healthy people aged 40–69 years whose risk factors are untreated or have been stable for several years.[1]
The SCORE2 investigators add that SCORE includes only fatal CVD outcomes, so it underestimates total CVD burden.[7] That burden has shifted towards non-fatal outcomes in recent decades, especially for younger people.[7]
Model development and validation (prediction model, not a treatment trial): sex-specific, competing risk-adjusted models with age, smoking status, systolic BP, and total and HDL cholesterol, recalibrated to four European risk regions defined by country-specific CVD mortality
Population: Derivation: individual-participant data from 45 cohorts in 13 countries (677 684 individuals, 30 121 CVD events); external validation: 25 additional cohorts in 15 European countries (1 133 181 individuals, 43 492 CVD events)
Key finding
Aim: estimate 10-year fatal and non-fatal CVD risk in individuals without previous CVD or diabetes aged 40–69 years in Europe
ESC/EAS 2025 notes that non-HDL cholesterol (total cholesterol minus HDL-C) is used as an input in SCORE2 and SCORE2-OP, where SCORE used total cholesterol.[2]
SCORE2-OP: 70 years and older
Older people need a different model.[1] ESC 2021 gives two reasons.[1] First, the gradient between classical risk factors, such as lipids and BP, and CVD risk attenuates with age.[1] Second, CVD-free survival dissociates from overall survival with age, because risk for non-CVD mortality increases ("competing risk").[1] Models that ignore this competing risk tend to overestimate 10-year CVD risk, and hence the potential benefit of treatment.[1] The SCORE2-OP algorithm estimates 5-year and 10-year fatal and non-fatal CVD events (MI, stroke) adjusted for competing risks in apparently healthy people aged ≥70 years.[1]
Model development and validation (prediction model): sex-specific, competing risk-adjusted models including age, smoking status, diabetes, systolic BP, and total and HDL cholesterol
Population: Derivation in people aged over 65 years without pre-existing atherosclerotic CVD from the Cohort of Norway (28 503 individuals, 10 089 CVD events)
Key finding
Aim: estimate 5- and 10-year CVD risk in people aged over 70 years in four geographical risk regions
ESC/EAS 2025 says SCORE2/SCORE2-OP can estimate 10-year risk of fatal and non-fatal CV events also for apparently healthy people aged ≥70 years (up to 89 years).[2]
Risk regions and reading the charts
SCORE2 and SCORE2-OP are calibrated to four clusters of countries, from low to very high CVD risk.[1] The clusters are grouped on national CVD mortality rates published by the WHO.[1] ESC 2021 lists the low-risk countries as Belgium, Denmark, France, Israel, Luxembourg, Norway, Spain, Switzerland, the Netherlands and the United Kingdom.[1] Its moderate-risk cluster includes Germany, Italy, Ireland and Sweden, and its high-risk cluster includes Poland, Hungary and Turkey.[1]
To read a chart, ESC 2021 says to start with the correct cluster of countries.[1] Then pick the risk table for the person's sex, smoking status and (nearest) age, and find the cell nearest to their BP and non-HDL-C.[1] Risk estimates then need to be adjusted upwards as the person approaches the next age category.[1]
SCORE2-Diabetes
Type 2 diabetes has its own European model.[10] ESC 2023 (diabetes guideline) recommends estimating 10-year CVD risk via SCORE2-Diabetes in type 2 DM without symptomatic ASCVD or severe target organ damage (TOD) (Class I, Level B); its footnote says SCORE2-Diabetes refers to patients aged ≥40 years.[10] Another footnote to the same row defines severe TOD as eGFR <45 mL/min/1.73 m² irrespective of albuminuria, or eGFR 45–59 mL/min/1.73 m² and microalbuminuria (UACR 30–300 mg/g; stage A2).[10] Proteinuria (UACR >300 mg/g; stage A3) also counts, as does microvascular disease in at least three different sites (e.g. microalbuminuria (stage A2) plus retinopathy plus neuropathy).[10] The model extends SCORE2 to people with type 2 DM aged 40–69 years without ASCVD or severe TOD.[10] It estimates 10-year risk of fatal and non-fatal CVD events (MI, stroke).[10] It adds diabetes-specific information, such as age at diabetes diagnosis, HbA1c and eGFR, to the conventional risk factors.[10] It was developed from four large datasets comprising 229 460 participants (43 706 CVD events) with type 2 diabetes and without previous CVD.[11]
PREVENT: the AHA equations, 30 to 79 years
PREVENT was developed and validated among US adults aged 30–79 years without known CVD.[9] The PREVENT paper says its derivation sample included individual-level data from 25 datasets (N=3,281,919) between 1992 and 2017.[9] The primary outcome was CVD (ASCVD and heart failure).[9] The models were sex-specific, race-free, developed on the age scale and adjusted for the competing risk of non-CVD death.[9] In external validation, the median C-statistics for CVD were 0.794 in female and 0.757 in male participants.[9]
Salient features of the PREVENT equations (ACC/AHA 2026 Table 11, all rows)
| ACC/AHA 2026 Table 11 feature | What it says |
|---|---|
| Sample | A large, contemporary, representative sample of US adults for derivation (N = ∼3.3 million) and external validation (N = ∼3.3 million) |
| Age range | Lower limit to begin risk prediction is age 30 years (through 79 years) |
| Sex and race | Sex-specific equations; race/ethnicity is not a variable that added predictive value; estimates are adjusted for competing risk of non-CVD death |
| Base model inputs | Age, sex, blood pressure, total and HDL-C, diabetes status, tobacco use, kidney function (eGFR), statin use and antihypertensive medication use (and BMI for heart failure prediction) |
| Optional inputs | Optional models with additional inputs, if known/measured: HbA1c, urinary albumin/creatinine ratio and zip code (social deprivation index); these are not necessary to generate risk estimates, but they may enhance risk prediction if available |
| Time horizons | 10-year and 30-year outcomes |
| Outcomes | Hard ASCVD (relevant for LLT decisions), heart failure, and total CVD (ASCVD plus heart failure; relevant for BP-lowering decisions) |
| Discrimination | Similar risk discrimination (C statistics) as the pooled cohort equations for prediction of ASCVD events |
| Calibration | Significantly and substantially more accurate risk estimates (improved calibration) for ASCVD than the pooled cohort equations, overall and in all demographic subgroups; in general, PREVENT-ASCVD estimates tend to be 40% to 50% lower than 10-year PCE estimates for the same risk factor profile |
Hard ASCVD in Table 11 means fatal or non-fatal stroke, non-fatal MI or coronary heart disease death; it does not include revascularisations performed without antecedent clinical events.[4] The 2026 AHA/ACC/ADA/ASN cardiovascular-kidney-metabolic (CKM) guideline uses PREVENT too.[12]
- CKM 2026 (COR 1, LOE B-NR): in adults aged 30 to 79 years without CVD (coronary heart disease, stroke, or HF), calculating 10-year risk of CVD (and its components, ASCVD and heart failure) with PREVENT is recommended to quantify risk related to CKM syndrome and to inform prevention strategies.[12]
- CKM 2026 (COR 2a, LOE B-NR): in adults aged 30 to 59 years without CVD (coronary heart disease, stroke, or HF), calculating 30-year risk of CVD (and its components) with PREVENT can be useful for the same purposes.[12]
The pooled cohort equations: dated history
The 2019 ACC/AHA primary prevention guideline is now dated history for risk estimation.[13][4][5] For adults 40 to 75 years, it recommended calculating 10-year ASCVD risk with the pooled cohort equations (PCE) (COR I, LOE B-NR).[13] For lipid decisions in adults aged 30 to 79 years without ASCVD or subclinical atherosclerosis and with LDL-C 70 to 189 mg/dL, the newer ACC/AHA 2026 dyslipidemia guideline says the PREVENT-ASCVD equations should be used to estimate 10-year ASCVD risk (COR 1, LOE B-NR).[4] For BP decisions, the 2025 AHA/ACC guideline recommends using PREVENT to estimate 10-year CVD risk in adults with hypertension without clinical CVD, to set the BP threshold for starting therapy.[5]
- Derivation (AHA/ACC 2025): the PCE came from 20,338 White adults and 4,288 Black adults with baseline examinations from the 1960s to the 1990s; PREVENT came from contemporary data on 3.2 million individuals with baseline examinations from 1992 to 2022 and a diverse sample of racial and ethnic groups.[5]
- Calibration (AHA/ACC 2025): in a contemporary sample of 3.3 million US adults, the PCE overpredicted risk by 2-fold, while PREVENT had excellent calibration, even when examined by race and ethnic group.[5]
Crosswalk between 10-year ASCVD estimates from the PCE and PREVENT-ASCVD (ACC/AHA 2026 Table 12)
| Risk group | PCE | PREVENT-ASCVD |
|---|---|---|
| Low | <5% | <3% |
| Borderline | 5% to <7.5% | 3% to <5% |
| Intermediate | 7.5% to <20% | 5% to <10% |
| High | ≥20% | ≥10% |
The table gives approximately equivalent ranges.[4] ACC/AHA 2026 says the categories of risk (borderline, intermediate, high) tend to identify similar groups of individuals using the newer, lower PREVENT-ASCVD thresholds and the older, higher PCE thresholds.[4] The reason is that the PCE overestimated ASCVD risk in many individuals.[4]
The Aus CVD Risk Calculator
The 2023 Australian guideline uses the Aus CVD Risk Calculator.[6] Its equation was developed from a large New Zealand cohort study, then customised and recalibrated for the Australian population.[6] The 2023 guideline replaces the 2012 guideline, which recommended CVD risk assessment using the Framingham risk equation.[6] New variables are social disadvantage, diabetes-specific risk markers, a diagnosis of atrial fibrillation, and use of BP-lowering and lipid-modifying therapies.[6] The Med J Aust summary says the share of the population at high risk (≥10% over five years) is likely to be broadly comparable to more than 15% risk from the Framingham-based equation.[6]
[4] [6] [1] [9] [7]Risk categories and thresholds by age
ESC 2021 sets a different cut-off for each age band.[1] The cut-offs are numerically different for various age groups to avoid undertreatment in the young and overtreatment in older persons.[1] Age is a major driver of CVD risk, but lifelong treatment benefit is higher in younger people.[1] So the risk thresholds for considering treatment are lower for younger people (Table 5).[1]
ESC 2021 Table 5: Cardiovascular disease risk categories based on SCORE2 and SCORE2-OP in apparently healthy people according to age
| Age | Low-to-moderate risk: risk factor treatment generally not recommended | High risk: risk factor treatment should be considered | Very high risk: risk factor treatment generally recommended (footnote a) |
|---|---|---|---|
| <50 years (SCORE2) | <2.5% | 2.5 to <7.5% | ≥7.5% |
| 50–69 years (SCORE2) | <5% | 5 to <10% | ≥10% |
| ≥70 years (SCORE2-OP; footnote a) | <7.5% | 7.5 to <15% | ≥15% |
ESC 2021 Table 5 footnote a: in apparently healthy people ≥70 years old, the treatment recommendation for lipid-lowering drugs is Class IIb ("may be considered").[1] For LDL-C decisions this page gives the newer ESC/EAS 2025 rows (When to treat: lipids), which use its Table 3 categories.[2] ESC/EAS 2025 says SCORE2/SCORE2-OP can estimate 10-year risk for fatal and non-fatal CV events also for apparently healthy people aged ≥70 years (up to 89 years).[2]
Two ESC 2021 rows sit behind the table.[1] Both apply to apparently healthy people without DM, CKD, or genetic/rarer lipid or BP disorders.[1]
-
Very high risk (Class I, Level C): treatment of ASCVD risk factors is recommended.[1]
-
High risk (Class IIa, Level C): treatment of ASCVD risk factors should be considered, taking ASCVD risk modifiers, lifetime risk and treatment benefit, and patient preferences into account.[1]
-
After the estimate (Class IIa, Level C): in apparently healthy people, lifetime risk and treatment benefit, risk modifiers, frailty, polypharmacy and patient preferences should be considered.[1]
-
Under 50: the 10-year risk in relatively young, apparently healthy people is on average low, even with high risk factor levels, but the lifetime risk is then very high; a 10-year risk ≥7.5% is generally considered "very high risk" because it relates to a high lifetime risk (ESC 2021).[1]
-
50–69: a 10-year CVD risk (fatal and non-fatal ASCVD events) ≥10% is generally considered "very high risk" (ESC 2021).[1]
-
70 and over: the estimated 10-year risk of almost all individuals ≥70 years exceeds conventional thresholds and lifetime benefit of treatment is lower, so the thresholds are higher (ESC 2021).[1]
-
Edges of the bands: the three age groups produce a discontinuous increase in thresholds, so ESC 2021 says sensible use requires some flexibility as patients move towards the next age group or have recently passed the age cut-off.[1]
-
Moving down a band without drugs: many patients can move themselves towards a lower risk category just by stopping smoking (ESC 2021).[1]
One more ESC 2021 statement explains the numbers.[1] In the 50–69-year range, a 10-year CVD mortality threshold of 5% with the old SCORE corresponds, on average, to a fatal and non-fatal threshold of 10% with SCORE2.[1] Approximately the same number of people are above each threshold and would qualify for treatment.[1]
[1]Newer ESC and ESC/EAS thresholds without age bands
Newer documents set their SCORE2/SCORE2-OP cut-offs without the 2021 age bands: ESC 2024 for BP decisions, and the ESC/EAS 2025 focused update in its Table 3 risk categories, which its primary-prevention LDL-C rows (Recommendation Table 1) use.[3][2] The ESC 2024 hypertension guideline chose a single risk threshold of ≥10% instead of age-specific thresholds such as those of the 2021 prevention guideline.[3] One reason it gives is that contemporary data show the heightened importance of BP control in older adults.[3] Their higher absolute CVD risk gives a lower number needed to treat, and BP control can reduce age-dependent adverse outcomes such as dementia.[3] The ESC/EAS 2025 dyslipidaemia focused update defines very high, high, moderate and low risk with SCORE2/SCORE2-OP for apparently healthy persons (Table 3).[2] As a general concept, it states that the risk of total CVD events is estimated to be 2–3 times higher than the risk of fatal CVD events, although this may vary considerably according to age and sex.[2] So it used a 2× multiplier to convert previous SCORE-based thresholds into SCORE2- or SCORE2-OP-based thresholds.[2]
Same question, different scores and cut-offs
| Guideline and decision | Score | Categories or threshold |
|---|---|---|
| ESC 2021 prevention: treatment of ASCVD risk factors | SCORE2 / SCORE2-OP, 10-year | Age-specific (Table 5, above) |
| ESC/EAS 2025: LDL-C (Table 3) | SCORE2 / SCORE2-OP, 10-year | Low <2%; moderate ≥2% and <10%; high ≥10% and <20%; very high ≥20% |
| ESC 2024: elevated BP | SCORE2 / SCORE2-OP, 10-year | ≥10%, irrespective of age, is increased risk (Class I, Level B) |
| ESC 2023: type 2 DM aged ≥40 years without symptomatic ASCVD or severe TOD | SCORE2-Diabetes, 10-year | Low <5%; moderate 5% to <10%; high 10% to <20%; very high ≥20% (Figure 3 footnote: these thresholds are not definitive but are designed to prompt joint decision-making conversations with patients about intensity of treatment and additional interventions) |
| ACC/AHA 2026: LLT (30 to 79 years, no ASCVD or subclinical atherosclerosis, LDL-C 70 to 189 mg/dL) | PREVENT-ASCVD, 10-year | Low <3%; borderline 3% to <5%; intermediate 5% to <10%; high ≥10% |
| AHA/ACC 2025: BP-lowering drugs (hypertension without clinical CVD) | PREVENT, 10-year risk for CVD events | ≥7.5% is increased risk (drug at average SBP ≥130 mm Hg, COR 1, LOE A) |
| Australia 2023 | Aus CVD Risk Calculator, 5-year | Low <5%; intermediate 5% to <10%; high ≥10% |
Note the time horizon: the Australian categories are 5-year risks, while the ESC and ACC/AHA categories are 10-year risks.[6][2][4] ESC 2023 adds that 10-year risk thresholds are for guidance only.[10] Other patient characteristics may lead to decisions to treat or not treat irrespective of such thresholds.[10]
Risk modifiers and risk enhancers
ESC/EAS 2025 calls existing population-based models relatively crude tools for individual risk prediction.[2] Attention to additional characteristics is particularly relevant around treatment decision thresholds.[2] ESC 2021 agrees: modifiers seem particularly relevant when risk is close to a decision threshold.[1] In low-risk or very-high-risk situations, additional information is less likely to alter management.[1]
ESC rows
ESC rows on risk modifiers (selected rows)
| Row | Source | Class, Level |
|---|---|---|
| Risk modifiers should be considered in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification | ESC/EAS 2025 Recommendation Table 1 | IIa, B |
| Stress symptoms and psychosocial stressors modify CVD risk; assessment of these stressors should be considered | ESC 2021 (Recommendations for CVD risk modifiers) | IIa, B |
| Multiplication of calculated risk by the relative risk for specific ethnic subgroups should be considered | ESC 2021 (Recommendations for CVD risk modifiers) | IIa, B |
| 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 | ESC 2021 (Recommendations for CVD risk modifiers) | III, B |
| History of pregnancy complications (gestational diabetes, gestational hypertension, pre-term delivery, pre-eclampsia, one or more stillbirths, and recurrent miscarriage) are sex-specific risk modifiers that should be considered to up-classify individuals with elevated BP and borderline increased 10-year CVD risk (5% to <10%) | ESC 2024 Recommendation Table 4 | IIa, B |
| 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%) | ESC 2024 Recommendation Table 4 | IIa, B |
- ESC 2021 ethnic correction factors (UK data): these could be applied when assessing CVD risk using risk calculators: multiply the risk by 1.3 for Indians and Bangladeshis and 1.7 for Pakistanis, 1.1 for other Asian groups, 0.85 for Black Caribbean, and 0.7 for Black African and Chinese people.[1]
- ESC/EAS 2025 Box 1 (Risk modifiers for consideration beyond the risk estimation based on the SCORE2 and SCORE2-OP algorithms), demographic/clinical conditions: 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.[2]
- ESC/EAS 2025 Box 1, biomarkers: persistently elevated hs-CRP (>2 mg/L); elevated Lp(a) [>50 mg/dL (>105 nmol/L)].[2]
ESC/EAS 2025 says their presence may support reclassifying a person to a higher category than SCORE2 or SCORE2-OP calculates.[2] They may thereby guide decisions about LDL-C goals and lipid-lowering interventions.[2]
ACC/AHA 2026 risk enhancers
ACC/AHA 2026 has two risk-enhancer rows, both for adults without ASCVD with a borderline 10-year PREVENT-ASCVD risk (3% to <5%), and a separate reproductive-marker row.[4]
- Risk enhancers (COR 2a, LOE B-NR): in adults without ASCVD with a borderline 10-year ASCVD risk (3% to <5%) by PREVENT-ASCVD, considering risk enhancers is reasonable to personalise risk assessment and the potential benefit of starting LLT as an adjunct to lifestyle management.[4]
- hsCRP (COR 2a, LOE B-R): in the same borderline group, 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.[4]
- Reproductive risk markers (COR 2a, LOE B-NR): in adults without ASCVD, considering early menopause (<45 years) and adverse pregnancy outcomes (gestational hypertension, pre-eclampsia, gestational diabetes, preterm delivery) is reasonable to personalise risk assessment when considering LLT.[4]
- Table 13 (Risk Enhancers): history of premature ASCVD in a parent or sibling (onset age <55 years for men, <65 years for women); higher risk ancestry (eg, South Asian, Filipino); high polygenic risk (if measured); chronic inflammatory diseases (eg, systemic lupus, rheumatoid arthritis, advanced psoriasis, inflammatory arthritis); Lp(a) ≥125 nmol/L or ≥50 mg/dL; hsCRP ≥2 mg/L on >1 occasion (if measured); triglycerides persistently ≥175 mg/dL (2 mmol/L) if non-fasting and ≥150 mg/dL (1.7 mmol/L) if fasting; CKM syndrome; LDL-C persistently ≥160–189 mg/dL (4.1–4.9 mmol/L), non-HDL-C ≥190–219 mg/dL or apoB ≥120 mg/dL; reproductive risk markers (premature menopause, pre-eclampsia, gestational diabetes, gestational hypertension, preterm delivery).[4]
- Caveat (ACC/AHA 2026): given the recent publication of the PREVENT-ASCVD equations, it remains to be demonstrated for most risk enhancers that risk is incremental to PREVENT-ASCVD.[4]
Australian reclassification factors
The 2023 Australian guideline says reclassification factors may be applied to recategorise calculated risk, particularly close to a risk threshold.[6] They are Indigenous status/ethnicity, eGFR, urine albumin to creatinine ratio, severe mental illness, CAC score and family history of premature CVD.[6]
ESC/EAS 2025 Box 1
Europe, selected items
- Family history of premature CVD: men <55 years; women <60 years
- Persistently elevated hs-CRP (>2 mg/L)
- Elevated Lp(a) [>50 mg/dL (>105 nmol/L)]
ACC/AHA 2026 Table 13
United States, selected items
- Premature ASCVD in a parent or sibling: onset <55 years for men, <65 years for women
- hsCRP ≥2 mg/L on >1 occasion (if measured)
- Lp(a) ≥125 nmol/L or ≥50 mg/dL
Coronary artery calcium scoring
The earlier ESC position, in ESC 2021, is that CAC scoring can reclassify CVD risk upwards and downwards in addition to conventional risk factors, and may thus be considered in men and women with calculated risks around decision thresholds.[1] The newer ESC/EAS 2025 row is given below.[2] ACC/AHA 2026 says assessment of subclinical coronary atherosclerosis gives valuable prognostic information in asymptomatic adults without known clinical ASCVD.[4] It says this assessment is generally recommended for use in men ≥40 years and women ≥45 years.[4] It categorises CAC as absent (0), minimal (1–9), mild (10–99), moderate (100–299), severe (300–999) and extensive (≥1000).[4]
ESC position
-
ESC/EAS 2025 (Class IIa, Level B), the newest ESC row among the guidelines checked: 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; its footnote says this revised row replaces the CAC row of the 2019 ESC/EAS dyslipidaemia guidelines.[2]
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ESC 2021 (Class IIb, Level B), the earlier row: CAC scoring may be considered to improve risk classification around treatment decision thresholds, with carotid ultrasound plaque detection as an alternative when CAC scoring is unavailable or not feasible.[1]
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Arterial plaque (ESC/EAS 2025): the focused update endorses the 2019 ESC/EAS recommendation that arterial (carotid and/or femoral) plaque burden should be considered as a risk modifier in individuals at low or moderate risk.[2]
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Evidence (ESC/EAS 2025): there are no randomised trials showing that using CAC to classify risk and guide management improves CV outcomes, but considering CAC improves both discrimination and reclassification, and improves the accuracy of risk predicted by SCORE2.[2]
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Graded risk (ESC/EAS 2025): an elevated CAC score is associated in a graded fashion with higher risk of adverse CV events in primary prevention; at markedly elevated values (e.g. CAC score >300), the risk was similar to or even higher than that of patients with known clinical ASCVD.[2]
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Zero (ESC/EAS 2025): a CAC score of zero has been associated with lower risk of ASCVD events and mortality in persons at low to moderate estimated CV risk.[2]
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Interpretation (ESC 2021): if CAC is detected, compare its extent with what would be expected for a patient of the same sex and age; higher-than-expected CAC increases calculated risk, whereas absent or lower-than-expected CAC is associated with lower than calculated risk.[1]
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Limits (ESC 2021): CAC scoring does not give direct information on total plaque burden or stenosis severity, and can be low or even zero in middle-aged patients with soft non-calcified plaque.[1]
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BP decisions (ESC 2024, Class IIb, Level B): after assessing 10-year predicted CVD risk and non-traditional risk modifiers, if a risk-based BP-lowering decision remains uncertain for individuals with elevated BP, measuring CAC score, carotid or femoral plaque on ultrasound, high-sensitivity cardiac troponin or B-type natriuretic peptide, or pulse wave velocity may be considered to improve risk stratification among patients with borderline increased 10-year CVD risk (5% to <10%), after shared decision-making and considering costs.[3]
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Type 2 DM (ESC 2023): there is not enough robust evidence to suggest that CAC or intima-media thickness help reclassify CV risk in people with type 2 DM.[10]
ACC/AHA 2026 rows
ACC/AHA 2026 Section 4.2.3.6: Selective Imaging of Subclinical Atherosclerosis (Men ≥40 or Women ≥45 Years), all rows
| Row | COR, LOE |
|---|---|
| Intermediate risk and select borderline risk, no prior ASCVD, decision on LLT uncertain: a CAC score should be used for further risk stratification and to guide the decision to withhold, postpone or initiate therapy | 1, B-R |
| Intermediate or select borderline risk 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 | 2a, B-NR |
| Intermediate and select borderline risk with CAC >0 AU: initiating LLT is recommended, particularly if the CAC score is ≥100 AU or ≥75th standardised percentile | 1, B-NR |
| Intermediate or high risk, no prior ASCVD, uncertainty about LLT intensity: a CAC score can be useful to refine treatment goals and decide whether to intensify | 2a, B-NR |
| No prior ASCVD, incidental CAC on non-cardiac CT (eg, by visual estimation or a validated AI-based algorithm): the presence of coronary atherosclerosis should be considered in decisions on starting or intensifying LLT to reduce ASCVD risk | 1, B-NR |
| No prior ASCVD, likely high burden of non-calcified plaque (eg, inflammatory disorders, HIV, diabetes): selective coronary CT angiography may be useful to inform risk assessment and LLT intensity | 2b, B-NR |
Why does CAC change decisions?[4] ACC/AHA 2026 cites observational studies in which as many as 40% of intermediate-risk adults have CAC=0, with very low 10-year event rates.[4] About 25% of intermediate-risk participants may have CAC ≥100, with 10-year event rates comparable to high-risk adults.[4] ACC/AHA 2026 says observational studies have consistently shown that among adults with CAC ≥100 the incident ASCVD event rate is >7.5%, the PCE threshold above which statin therapy has been shown to be beneficial.[4] Adults with CAC ≥300 have event rates similar to adults with established, treated ASCVD.[4]
Once CAC is found, ACC/AHA 2026 Section 4.2.7 (Management of Adults With Subclinical Coronary Atherosclerosis, Men ≥40 or Women ≥45 Years) sets treatment goals in six rows, given here in source order.[4]
- CAC ≥1000 AU (COR 1, LOE B-NR): LDL-C-lowering therapy, with statin therapy considered first line, is recommended to achieve a ≥50% reduction in LDL-C and a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non-HDL-C <85 mg/dL (2.2 mmol/L).[4]
- CAC ≥300 to 999 AU (COR 1, LOE B-R): LDL-C-lowering therapy, with statin therapy considered first line, is recommended to achieve a ≥50% lowering in LDL-C and a goal LDL-C <70 mg/dL (1.8 mmol/L) and non-HDL-C <100 mg/dL (2.6 mmol/L).[4]
- CAC ≥100 to 299 AU or ≥75th standardised percentile (COR 1, LOE B-R): LLT, with statin therapy considered first-line therapy, is recommended to achieve a ≥50% reduction in LDL-C and a goal LDL-C <70 mg/dL (1.8 mmol/L) and non-HDL-C <100 mg/dL (2.6 mmol/L).[4]
- CAC 1 to 99 AU and <75th standardised percentile, or an incidental finding of mild CAC on non-cardiac CT (COR 2a, LOE B-R): moderate-intensity statin therapy is reasonable to achieve a ≥30% to 49% reduction in LDL-C and a goal of LDL-C <100 mg/dL (2.6 mmol/L) and non-HDL-C <130 mg/dL (3.4 mmol/L).[4]
- CAC ≥300 to 999 AU, intensification (COR 2a, LOE B-NR): it is reasonable to intensify therapy by increasing the intensity of statin therapy or, if needed, adding ezetimibe, a PCSK9 mAb or bempedoic acid to achieve a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non-HDL-C <85 mg/dL (2.2 mmol/L).[4]
- No prior ASCVD, incidental coronary atherosclerosis on non-cardiac CT, eg, by visual estimation or a validated AI-based algorithm (COR 2a, LOE B-NR): if moderate to severe, it is reasonable to initiate high-intensity statin therapy to achieve at least a ≥50% reduction in LDL-C and a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non-HDL-C <100 mg/dL (2.6 mmol/L); if mild, moderate-intensity statin therapy is reasonable to achieve a ≥30% to 49% reduction in LDL-C and a goal of LDL-C <100 mg/dL (2.6 mmol/L) and non-HDL-C <130 mg/dL.[4]
The Australian guideline and the dated 2019 ACC/AHA guideline also address CAC.[13][6] The 2023 Australian guideline lists CAC score among its reclassification factors.[6] The 2019 ACC/AHA guideline, now dated history, said measuring a CAC score is reasonable to guide the risk discussion when decisions remain uncertain (COR IIa, LOE B-NR).[13] That row applied to adults at intermediate 10-year ASCVD risk (≥7.5% to <20%) or selected adults at borderline risk (5% to <7.5%).[13]
[4] [2]When to treat: lipids
This section gives the risk triggers; goals, statin intensity and add-on drugs are in Dyslipidaemia: LDL-C targets, statin intensity, ezetimibe and PCSK9 inhibitors.[2][4]
ESC/EAS 2025
- Class I, Level A: in primary prevention, pharmacological LDL-C-lowering therapy is recommended in persons at very high risk with LDL-C ≥1.8 mmol/L (70 mg/dL), or at high risk with LDL-C ≥2.6 mmol/L (100 mg/dL), despite optimisation of non-pharmacological measures, to lower CVD risk.[2]
- Class IIa, Level A: it should be considered in persons at very high risk with LDL-C ≥1.4 mmol/L (55 mg/dL) but <1.8 mmol/L (70 mg/dL); at high risk with LDL-C ≥1.8 mmol/L (70 mg/dL) but <2.6 mmol/L (100 mg/dL); at moderate risk with LDL-C ≥2.6 mmol/L (100 mg/dL) but <4.9 mmol/L (190 mg/dL); or at low risk with LDL-C ≥3.0 mmol/L (116 mg/dL) but <4.9 mmol/L (190 mg/dL), despite optimisation of non-pharmacological measures.[2]
Here "risk" means the ESC/EAS 2025 Table 3 categories, set either by a listed condition or by SCORE2/SCORE2-OP.[2] By SCORE2 or SCORE2-OP, <2% is low, ≥2% and <10% moderate, ≥10% and <20% high, and ≥20% very high.[2]
ACC/AHA 2026 (adults 30 to 79 years with LDL-C 70 to 189 mg/dL)
ACC/AHA 2026 Section 4.2.3.7: selected rows under their source group headings
| Source group heading | Row | COR, LOE |
|---|---|---|
| None (opening row, before the group headings) | Adults being assessed for primary prevention of ASCVD: health behaviour recommendations should be provided in addition to a benefit-risk discussion for consideration of LLT | 1, A |
| Low (<3%) estimated 10-year ASCVD risk | Aged 30 to 59 years, at low (<3%) 10-year risk, with LDL-C <160 mg/dL (4.1 mmol/L) and a 30-year risk estimate of <10%: counselling on health behaviours is recommended to reduce LDL-C and risk for ASCVD | 1, A |
| Low (<3%) estimated 10-year ASCVD risk | Aged 30 to 59 years, at low (<3%) 10-year risk but with LDL-C 160 to 189 mg/dL (4.1–4.9 mmol/L) or a 30-year ASCVD risk ≥10%: a moderate-intensity statin is reasonable to reduce cumulative exposure to atherogenic lipoproteins | 2a, C-LD |
| Borderline (3% to <5%) and intermediate (5% to <10%) 10-year ASCVD risk | Borderline risk, when a decision is made to start statin therapy for primary prevention: a moderate-intensity statin is reasonable to achieve ≥30% to 49% LDL-C reduction and to reduce ASCVD risk | 2a, A |
| Borderline (3% to <5%) and intermediate (5% to <10%) 10-year ASCVD risk | Intermediate risk: at least a moderate-intensity statin is recommended to achieve ≥30% to 49% LDL-C reduction and to reduce ASCVD risk; for those in the higher end of this risk range, a high-intensity statin is beneficial to further reduce LDL-C by ≥50% and reduce ASCVD risk | 1, A |
| Borderline (3% to <5%) and intermediate (5% to <10%) 10-year ASCVD risk | Borderline or intermediate risk, once statin therapy is initiated: it is reasonable to treat to a goal of LDL-C <100 mg/dL (2.6 mmol/L) and non-HDL-C <130 mg/dL (3.4 mmol/L) to reduce ASCVD risk | 2a, B-NR |
| High (≥10%) 10-year estimated ASCVD risk | When LLT is initiated for primary prevention: high-intensity statin therapy is recommended to achieve an LDL-C reduction of ≥50% to reduce the risk of ASCVD | 1, A |
| High (≥10%) 10-year estimated ASCVD risk | When a decision to initiate statin therapy is made: it is reasonable to treat to a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non-HDL-C <100 mg/dL (2.6 mmol/L) to reduce ASCVD risk | 2a, B-R |
| Special considerations in primary prevention | Baseline untreated LDL-C <70 mg/dL (1.8 mmol/L) and non-HDL-C <100 mg/dL (2.6 mmol/L), without additional ASCVD risk factors: initiation of LLT for primary prevention is unlikely to reduce ASCVD risk | 3: No Benefit, B-NR |
Why 3%?[4] ACC/AHA 2026 cites the demonstrated benefits of statins even at lower event rates and the low rates of potential harms.[4] So a net benefit threshold as low as a predicted ASCVD risk of 3% is now recommended for consideration of LLT.[4] In primary prevention statin trials, net benefit was demonstrated for moderate-intensity statin at an event rate of ≥3% in 10 years.[4]
ACC/AHA 2026 also notes that 10-year estimation alone is poorly aligned with the long latency between risk factor exposure and events.[4] Estimating 30-year risk in those at low 10-year risk may help identify people who may benefit from LLT over longer horizons.[4]
The 2026 CKM guideline summarises these dyslipidemia thresholds in its Table 8.[12] Initiation of lipid-lowering treatment is recommended at a 10-year PREVENT-ASCVD risk ≥5%.[12] It is considered at 3% to <5% after evaluation of risk enhancers, 30-year risk or CAC when there is uncertainty, and at a 30-year PREVENT-ASCVD risk ≥10%.[12]
Australia (2023)
The 2023 Australian guideline says BP-lowering and lipid-modifying drugs should be prescribed for high-risk and considered for intermediate-risk individuals, unless contraindicated or clinically inappropriate.[6]
[4] [6] [2]When to treat: blood pressure
Measurement, confirmation and staging are covered in Hypertension: diagnosis and staging; this section gives only the risk-based treatment triggers.[3][5]
ESC 2024 (Recommendation Table 17)
- Elevated BP (office SBP 120–139 or DBP 70–89 mmHg) with low/medium risk (<10% over 10 years): BP lowering with lifestyle measures is recommended and can reduce CVD risk (Class I, Level B).[3]
- Elevated BP with sufficiently high CVD risk: after 3 months of lifestyle intervention, pharmacological BP lowering is recommended for those with confirmed BP ≥130/80 mmHg to reduce CVD risk (Class I, Level A).[3]
- "Sufficiently high risk" (footnote c): a 10-year estimated CVD risk ≥10%; or 5%–≤10% plus risk modifiers or abnormal risk tool tests; or high-risk conditions (e.g. established CVD, diabetes, moderate or severe CKD, FH, or HMOD).[3]
- Confirmed hypertension (BP ≥140/90 mmHg): lifestyle measures and pharmacological treatment are recommended promptly, irrespective of CVD risk (Class I, Level A).[3]
- Lifelong treatment: it is recommended to maintain BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated (Class I, Level A).[3]
- Selected groups (Class IIa, Level B): because the benefit in reducing CVD outcomes is uncertain in these settings, and noting that close monitoring of treatment tolerance is advised, BP-lowering treatment should only be considered from ≥140/90 mmHg among persons with pre-treatment symptomatic orthostatic hypotension, age ≥85 years, clinically significant moderate-to-severe frailty, and/or limited predicted lifespan (<3 years).[3]
ESC 2024 Recommendation Table 3 supplies the scores (both Class I, Level B).[3] SCORE2 is recommended in people aged 40–69 years with elevated BP, and SCORE2-OP in those aged ≥70 years.[3] Both rows exclude people already at increased risk from moderate or severe CKD, established CVD, HMOD, diabetes or FH.[3] ESC 2024 prefers these models because they predict fatal and non-fatal events and have been validated and recalibrated to European populations.[3] SCORE2-OP is also adjusted for the competing risk of non-cardiovascular mortality.[3]
AHA/ACC 2025 (Section 5.2.2)
AHA/ACC 2025: BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension (selected rows)
| Row | COR, LOE |
|---|---|
| All adults with hypertension: start medication when average SBP is ≥140 mm Hg | 1, A |
| All adults with hypertension: start medication when average DBP is ≥90 mm Hg | 1, A |
| Hypertension without clinical CVD but with diabetes or CKD or increased short-term CVD risk (10-year PREVENT CVD risk ≥7.5%): start medication when average SBP is ≥130 mm Hg | 1, A |
| Same group: start medication when average DBP is ≥80 mm Hg | 1, C-LD |
| Hypertension without clinical CVD and 10-year PREVENT risk <7.5%: start medication if average SBP remains ≥130 mm Hg after a 3- to 6-month trial of lifestyle intervention | 1, B-R |
| Same group: start medication if average DBP is ≥80 mm Hg after a 3- to 6-month trial of lifestyle intervention | 1, B-R |
AHA/ACC 2025 defines increased short-term or 10-year risk as a 10-year predicted risk for CVD events of ≥7.5% based on PREVENT.[5] PREVENT estimates total CVD (MI, stroke and heart failure), whereas the PCE estimate ASCVD.[5] AHA/ACC 2025 notes that trials of antihypertensive therapy have focused on major adverse cardiovascular events.[5]
[5] [3]How the scores differ
SCORE2, PREVENT and the Aus calculator side by side
| Feature | SCORE2 / SCORE2-OP (ESC) | PREVENT (AHA) | Aus CVD Risk Calculator |
|---|---|---|---|
| Who | Apparently healthy people in Europe: SCORE2 40–69 years; SCORE2-OP ≥70 years | US adults aged 30–79 years without known CVD | People without known CVD; assessment recommended at 45–79 years, from 35 years with diabetes and from 30 years for First Nations people |
| Outcome | Fatal and non-fatal CVD events (MI, stroke) | Predicts hard ASCVD, heart failure and total CVD | CVD risk |
| Horizon | 10-year (SCORE2-OP also 5-year) | 10-year and 30-year | 5-year |
| Development and calibration | Calibrated to four clusters of countries by national CVD mortality | Derived from 25 datasets (N=3,281,919), 1992–2017 | Based on an equation developed from a large New Zealand cohort; customised and recalibrated for Australia |
| Competing risk | Competing risk-adjusted models | Adjusted for competing risk of non-CVD death | Not stated in the held summary |
| Notable inputs | Age, smoking, systolic BP, total and HDL cholesterol (SCORE2-OP adds diabetes) | Adds eGFR, statin use and antihypertensive use; optional HbA1c, urine albumin/creatinine ratio and zip code | Adds social disadvantage, diabetes-specific markers, atrial fibrillation, and BP-lowering and lipid-modifying therapy use |
The practical consequence is that the same percentage means different things under each framework.[4][6][2] A SCORE2 of 4% is moderate risk under ESC/EAS 2025 Table 3.[2] A PREVENT-ASCVD estimate of 4% is borderline under ACC/AHA 2026.[4] An Australian 4% is a 5-year risk in the low band.[6] Always name the score, its horizon and the guideline whose thresholds you are applying.[2][4][6]
Special populations
- Younger adults (ESC 2021): CVD risk predictions and predictions of lifetime benefit are likely to be imprecise at very young age (<40 years); at that age lipid-lowering and BP-lowering drugs are not usually considered, except for patients with FH or specific BP disorders.[1]
- Younger adults with elevated BP (ESC 2024): since SCORE2 has not been validated for individuals <40 years, screening for HMOD may be considered in young people with elevated BP without other increased-risk conditions (Class IIb, Level B).[3]
- Lifetime view (ESC 2021): lifetime risk is the age at which there is a 50% probability that a person will have had a CVD event or died; there are currently no formal treatment thresholds for average lifetime benefit.[1]
- Risk age (ESC 2021): the age of a person of the same sex with the same level of risk but with low levels of risk factors.[1]
- Older adults: SCORE2-OP adjusts for competing risk, and ESC 2021 sets higher thresholds from 70 years.[1]
- Diabetes: ESC 2023 recommends estimating 10-year CVD risk via SCORE2-Diabetes in type 2 DM without symptomatic ASCVD or severe TOD (Class I, Level B), and its footnote says SCORE2-Diabetes refers to patients aged ≥40 years, with risk factors for ASCVD evaluated on an individual basis below 40 years.[10]
- ESC 2024 says SCORE2-Diabetes should be considered to estimate CVD risk among people with type 2 DM and elevated BP, particularly if they are <60 years (Class IIa, Level B); ACC/AHA 2026 notes that in persons >40 years with diabetes or CKD, or living with HIV, statins have shown benefit even at lower absolute ASCVD risk.[3][4]
- Chronic kidney disease: ESC/EAS 2025 Table 3 places severe CKD (eGFR <30) at very high risk and moderate CKD (eGFR 30–59) at high risk; PREVENT incorporates kidney function because CKD is an important end-organ manifestation of hypertension associated with higher CVD risk (AHA/ACC 2025).[2][5]
- Women: ESC 2024 says a history of pregnancy complications (gestational diabetes, gestational hypertension, pre-term delivery, pre-eclampsia, one or more stillbirths, and recurrent miscarriage) are sex-specific risk modifiers 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); ACC/AHA 2026 says that in adults without ASCVD, considering reproductive risk markers such as early menopause (<45 years) and a history of adverse pregnancy outcomes (gestational hypertension, preeclampsia, 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).[3][4]
- Pregnancy: ESC 2021 says the SCORE2 charts do not apply in pregnant women.[1]
- First Nations people (Australia): CVD risk assessment is recommended from 30 years.[6]
Evidence, guidelines and regional differences
Europe (ESC)
SCORE2 family
- SCORE2 under 70 and SCORE2-OP from 70, in apparently healthy people without established ASCVD, DM, CKD or genetic/rare lipid or BP disorders, for 10-year fatal and non-fatal CVD: Class I, Level B (ESC/EAS 2025)
- Age-specific thresholds for treating ASCVD risk factors (ESC 2021 Table 5); ESC 2024 (BP) and ESC/EAS 2025 Table 3 set SCORE2/SCORE2-OP cut-offs without age bands
- Single ≥10% threshold, irrespective of age, for BP decisions (ESC 2024); SCORE2-Diabetes in type 2 DM aged ≥40 years without symptomatic ASCVD or severe TOD (ESC 2023)
- CAC or subclinical coronary atherosclerosis as a risk modifier at moderate risk or around decision thresholds: Class IIa, Level B (ESC/EAS 2025)
United States (ACC/AHA)
PREVENT
- PREVENT-ASCVD for LLT decisions in adults 30 to 79 years without ASCVD or subclinical atherosclerosis with LDL-C 70 to 189 mg/dL: COR 1, LOE B-NR (ACC/AHA 2026)
- In hypertension without clinical CVD, PREVENT ≥7.5% (or diabetes or CKD) lowers the medication threshold to average SBP ≥130 or DBP ≥80 mm Hg (AHA/ACC 2025)
- CAC to stratify intermediate or select borderline risk with no prior ASCVD (men ≥40 or women ≥45 years) when the LLT decision remains uncertain: COR 1, LOE B-R (ACC/AHA 2026)
Australia
2023 guideline
- Aus CVD Risk Calculator, 5-year risk: low <5%, intermediate 5% to <10%, high ≥10%
- Reassessment of CVD risk should be considered within five years at low risk and within two years at intermediate risk; reassessment is not recommended at high risk
Guidelines checked for this topic
- ESC: 2021 prevention guideline, 2025 ESC/EAS dyslipidaemia focused update, 2024 hypertension guideline and 2023 diabetes guideline.[1][2][3][10]
- ACC/AHA: 2026 dyslipidemia guideline, 2025 high blood pressure guideline and 2026 AHA/ACC/ADA/ASN CKM guideline.[4][5][12]
- Australia: 2023 guideline for assessing and managing CVD risk.[6]
- Score papers: SCORE2, SCORE2-OP, SCORE2-Diabetes and PREVENT development papers.[7][8][11][9]
The 2021 ESC prevention guideline is the newest ESC guideline on CVD prevention among the guidelines checked for this topic (census 2026-10-09). Where a newer ESC document covers the same decision, the newer row is given beside it. The 2026 ACC/AHA dyslipidemia guideline retires and replaces the 2018 AHA/ACC multisociety blood cholesterol guideline.[4] The 2019 ACC/AHA primary prevention guideline appears only as dated history for its pooled cohort equation and CAC rows.[13] The 2026 ESC guideline on cardiovascular disease and chronic kidney disease is not held as text for this topic and is not used. The Australian guideline is quoted from its Med J Aust summary abstract only, because the full guideline is not held as text for this topic.[6]
Pitfalls
Exam pearls
- SCORE2: 10-year fatal and non-fatal CVD (MI, stroke), apparently healthy, 40–69 years; SCORE2-OP: 70 years and older, adjusted for competing risks (ESC 2021).[1]
- ESC 2021, apparently healthy people without DM, CKD, or genetic/rarer lipid or BP disorders: treatment of ASCVD risk factors is recommended at very high risk, ≥7.5% under 50, ≥10% at 50–69, ≥15% from 70 (Class I, Level C), and should be considered at high risk, 2.5 to <7.5%, 5 to <10%, 7.5 to <15%, taking CVD risk modifiers, lifetime risk and treatment benefit, and patient preferences into account (Class IIa, Level C).[1]
- ESC/EAS 2025 Table 3: SCORE2/SCORE2-OP <2% low, ≥2% and <10% moderate, ≥10% and <20% high, ≥20% very high.[2]
- ACC/AHA 2026 PREVENT-ASCVD, adults aged 30 to 79 years without ASCVD or subclinical atherosclerosis with LDL-C 70 to 189 mg/dL: <3% low, 3% to <5% borderline, 5% to <10% intermediate, ≥10% high (COR 1, LOE B-NR).[4]
- BP: ESC 2024 recommends that, irrespective of age, people with elevated BP and a SCORE2 or SCORE2-OP risk ≥10% be considered at increased risk for CVD for the purposes of risk-based management of their elevated BP (Class I, Level B); AHA/ACC 2025 recommends starting BP-lowering medication at average SBP ≥130 mm Hg, to reduce the risk of CVD events and total mortality, in adults with hypertension without clinical CVD who have diabetes, CKD or a 10-year PREVENT CVD risk ≥7.5% (COR 1, LOE A).[3][5]
- CAC: ESC/EAS 2025 Class IIa, Level B as a risk modifier at moderate risk or around treatment decision thresholds; ACC/AHA 2026 COR 1, LOE B-R to stratify intermediate or select borderline risk with no prior ASCVD (men ≥40 or women ≥45 years) when the LLT decision remains uncertain.[2][4]
- Australia: Aus CVD Risk Calculator, 5-year risk; high ≥10%, intermediate 5% to <10%, low <5%; assessment is recommended in people without known CVD aged 45–79 years, from 35 years with diabetes and from 30 years for First Nations people.[6]
References13ShowHide
- [1]Visseren FLJ, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J, 2021.PMID 34458905
- [2]Mach F, et al. 2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J, 2025.PMID 40878289
- [3]McEvoy JW, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J, 2024.PMID 39210715
- [4]Blumenthal RS, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2026.PMID 41824590
- [5]Jones DW, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2025.PMID 40815242
- [6]Nelson MR, et al. 2023 Australian guideline for assessing and managing cardiovascular disease risk. Med J Aust, 2024.PMID 38623719
- [7]SCORE2 working group and ESC Cardiovascular risk collaboration, et al. SCORE2 risk prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in Europe. Eur Heart J, 2021.PMID 34120177
- [8]SCORE2-OP working group and ESC Cardiovascular risk collaboration, et al. SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions. Eur Heart J, 2021.PMID 34120185
- [9]Khan SS, et al. Development and Validation of the American Heart Association's PREVENT Equations. Circulation, 2024.PMID 37947085
- [10]Marx N, et al. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J, 2023.PMID 37622663
- [11]SCORE2-Diabetes Working Group and the ESC Cardiovascular Risk Collaboration, et al. SCORE2-Diabetes: 10-year cardiovascular risk estimation in type 2 diabetes in Europe. Eur Heart J, 2023.PMID 37247330
- [12]Ndumele CE, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2026.PMID 42265997
- [13]Arnett DK, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 2019.PMID 30879355