MDCalc

ASCVD (Atherosclerotic Cardiovascular Disease) Risk Algorithm including Known ASCVD from AHA/ACC

Determines 10-year risk of hard ASCVD, i.e. myocardial infarction, stroke, or death due to coronary heart disease or stroke, and provides statin recommendations.

  • This calculator includes inputs based on race, which may or may not provide better estimates, so we have decided to make race optional. See here for more on our approach to addressing race and bias on MDCalc.
  • For the same other inputs, this calculator estimates higher cardiovascular risk for African American patients.
  • Looking for a race-free equation to calculate CVD risk? Check out the new PREVENT score.

Step 1: High-Risk Criteria: History of ASCVD

History of ASCVD

History of acute coronary syndrome (ACS), myocardial infarction (MI), stable angina, coronary/other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease (PAD) from atherosclerosis

Result:

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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.

The risk of statin-related adverse effects are generally intensity-dependent.

Additional Factors that are ASCVD Risk Enhancers per the 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.
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