Cardiovascular risk prediction and when to treat — viva

Stem

Practice viva. The examiner asks how you would decide whether an apparently well 58-year-old needs a statin or BP tablets, and works through who to score, which score, the thresholds, risk modifiers, coronary artery calcium, and how ESC, ACC/AHA and Australian practice differ.^[2][4][6]

Branch A — Who gets a score?

Examiner: Whom would you not put through a risk calculator?^[1]

Strong answer:

• ESC 2021: 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 (Class I, Level A); ESC 2021 also says 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; for type 2 DM the newer ESC 2023 row below applies.^[1][10]
• ESC/EAS 2025 Table 3 sets the category directly for, among others, documented ASCVD (very high), severe CKD with eGFR <30 mL/min/1.73 m² (very high), moderate CKD with eGFR 30–59 (high) and FH without other major risk factors (high).^[2]
• ESC 2023: in type 2 DM without symptomatic ASCVD or severe target organ damage, it is recommended to estimate 10-year CVD risk via SCORE2-Diabetes (Class I, Level B); its footnote says SCORE2-Diabetes refers to patients aged ≥40 years, and below 40 years risk factors for ASCVD should be evaluated on an individual basis.^[10]
• ACC/AHA 2026: in heterozygous FH, standard risk assessment tools developed for the general population should not be used to calculate 10- or 30-year ASCVD risk (COR 3: Harm, LOE C-EO).^[4]

Follow-up: Who should be assessed?^[1][6]

• ESC 2021: systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor (Class I, Level C); systematic or opportunistic assessment in men >40 and women >50 or postmenopausal without known risk factors may be considered (Class IIb, Level C); systematic assessment in men <40 and women <50 without known risk factors is not recommended (Class III, Level C).^[1]
• Australia 2023: all people aged 45–79 years without known CVD, people with diabetes from 35 years and First Nations people from 30 years.^[6]

Branch B — Which score?

Examiner: Compare SCORE2 and PREVENT.^[1][9]

Strong answer:

• SCORE2 estimates 10-year fatal and non-fatal CVD events (MI, stroke) in apparently healthy people aged 40–69 years with risk factors that are untreated or have been stable for several years, and SCORE2-OP estimates 5- and 10-year events adjusted for competing risks from 70 years (ESC 2021).^[1]
• SCORE2 was derived in 45 cohorts from 13 countries and recalibrated to four European risk regions defined by country-specific CVD mortality.^[7]
• PREVENT was developed among US adults aged 30–79 years without known CVD; it is sex-specific, race-free and adjusted for competing risk of non-CVD death.^[9]
• ACC/AHA 2026 Table 11: PREVENT predicts 10-year and 30-year risk of hard ASCVD, heart failure and total CVD, and its base model includes eGFR, statin use and antihypertensive use.^[4]

Follow-up: Why did the US move away from the pooled cohort equations?^[5]

• AHA/ACC 2025: the PCE were derived from 20,338 White and 4,288 Black adults with baseline examinations from the 1960s to the 1990s; in a contemporary sample of 3.3 million US adults, the PCE overpredicted risk by 2-fold while PREVENT had excellent calibration.^[5]
• ACC/AHA 2026: PREVENT-ASCVD estimates tend to be 40% to 50% lower than PCE estimates for the same profile, so the newer thresholds are lower (Table 12).^[4]

Branch C — Thresholds

Examiner: What 10-year risk makes a 58-year-old in Europe "very high risk"?^[1]

Strong answer:

• Under ESC 2021, a SCORE2 of ≥10% at 50–69 years; treatment of ASCVD risk factors is recommended in apparently healthy people without DM, CKD, or genetic/rarer lipid or BP disorders at very high risk (Class I, Level C).^[1]
• Under ESC 2021, for the same apparently healthy people, very high risk is also a SCORE2 of ≥7.5% under 50 years and a SCORE2-OP of ≥15% at 70 years or older; high risk is a SCORE2 of 2.5 to <7.5% under 50, a SCORE2 of 5 to <10% at 50–69 and a SCORE2-OP of 7.5 to <15% at 70 or older, where 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]
• For LDL-C, ESC/EAS 2025 Table 3 uses <2% low, ≥2% and <10% moderate, ≥10% and <20% high and ≥20% very high; for BP, ESC 2024 treats a SCORE2 or SCORE2-OP of ≥10% as increased risk irrespective of age (Class I, Level B).^[2][3]

Follow-up: And in the United States?^[4][5]

• ACC/AHA 2026, adults aged 30 to 79 years without ASCVD or subclinical atherosclerosis with LDL-C 70 to 189 mg/dL: PREVENT-ASCVD <3% low, 3% to <5% borderline, 5% to <10% intermediate and ≥10% high (COR 1, LOE B-NR); at intermediate risk at least a moderate-intensity statin is recommended (COR 1, LOE A).^[4]
• AHA/ACC 2025: in adults with hypertension without clinical CVD who have diabetes, CKD or a 10-year PREVENT CVD risk ≥7.5%, BP-lowering medication is recommended from an average SBP of ≥130 mm Hg (COR 1, LOE A).^[5]

Branch D — Refining the estimate

Examiner: The estimate sits near a threshold. What next?^[2]

Strong answer:

• ESC/EAS 2025: risk modifiers should be considered in individuals at moderate risk or around treatment decision thresholds (Class IIa, Level B), and subclinical coronary atherosclerosis by imaging or an increased CAC score by CT should be considered as risk modifiers in the same people (Class IIa, Level B).^[2]
• ACC/AHA 2026 (Section 4.2.3.6, men ≥40 or women ≥45 years): in intermediate and select borderline risk with no prior ASCVD and an uncertain LLT decision, a CAC score should be used for further risk stratification and to guide whether to withhold, postpone or initiate therapy (COR 1, LOE B-R); with CAC >0, initiating LLT is recommended, particularly at ≥100 AU or ≥75th standardised percentile (COR 1, LOE B-NR).^[4]
• ESC 2021: modifiers should move risk in both directions, and their effect on absolute risk is generally much smaller than their reported relative risks.^[1]

Follow-up: When does a CAC of zero not reassure you?^[4]

• ACC/AHA 2026 names FH or severe hypercholesterolaemia >190 mg/dL, diabetes, current tobacco use and a strong family history of premature ASCVD as important exceptions; in diabetes, CAC=0 was associated with low 5-year event rates, but risk increased substantially thereafter.^[4]
• ESC 2021: CAC can be low or even zero in middle-aged patients with soft non-calcified plaque.^[1]

Branch E — Australia

Examiner: How does Australian practice differ?^[6]

Strong answer:

• The 2023 Australian guideline uses the Aus CVD Risk Calculator, based on an equation from a large New Zealand cohort study and recalibrated for Australia, and replaces the Framingham-based approach of 2012.^[6]
• It gives 5-year risk: low <5%, intermediate 5% to <10%, high ≥10%; BP-lowering and lipid-modifying drugs should be prescribed at high risk and considered at intermediate risk, unless contraindicated or clinically inappropriate.^[6]
• Reclassification factors, including CAC score, may be applied, particularly close to a risk threshold.^[6]