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.
Patients at risk for atherosclerotic cardiovascular disease (ASCVD).
Clinical 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.
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
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Family history of premature ASCVD.
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Persistently elevated LDL-C levels at or above 160 mg/dL (4.1 mmol/L).
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Chronic kidney disease.
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Metabolic syndrome.
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Conditions specific to women (e.g. preeclampsia, premature menopause).
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Inflammatory diseases (especially rheumatoid arthritis, psoriasis, HIV).
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Ethnicity (e.g. South Asian ethnicity).
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Persistently elevated triglycerides levels at or above 175 mg/dL (2.0 mmol/L).
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And in selected individuals if measured:
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High-sensitivity C-reactive protein (hsCRP) levels at or above 2.0 mg/L.
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Lp(a) levels above 50 mg/dL (125 nmol/L).
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ApoB at or above 130 mg/dL.
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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.
Additional Information
- These estimates may underestimate the 10-year risk for some race/ethnic groups, including American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans).
- It may overestimate the risk for some Asian Americans (i.e., of east Asian ancestry) and some Hispanics (i.e., Mexican Americans).
- Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.
US Preventive Services Task Force (USPSTF) Guidelines
In 2016, the US Preventive Services Task Force (USPSTF) made similar but slightly different recommendations for adults without a history of cardiovascular disease (CVD) to use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met:
- Age 40 to 75 years.
- 1 or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking).
- Calculated 10-year risk of a cardiovascular event of 10% or greater (B recommendation).
The USPSTF gave a B recommendation—indicating high certainty that the benefit is moderate or moderate certainty that the benefit is moderate to substantial—for starting low- to moderate-dose statins in adults ages 40 to 75 years without a history of cardiovascular disease (CVD) who have one or more CVD risk factors and a 10-year CVD risk of 10% or greater.
The USPSTF dropped its level of endorsement to C for adults with a lower 1-year risk (7.5%-10%) and made no recommendations for adults 76 years of age and older, explaining that there was insufficient evidence for this age group.
*Thanks to Vijay Shetty, MBBS, for this summary of the 2016 USPSTF guidelines.
Intensity of Statin Therapy
| Type of Statin | Taken Daily, Average LDL Lowering Effect | Types of Medication |
|---|---|---|
| High-Intensity Statin Therapy | Approximately ≥50% | Atorvastatin 40–80 mg |
| Rosuvastatin 20-40 mg | ||
| Moderate-Intensity Statin Therapy | Approximately 30% to <50% | Atorvastatin 10-20 mg |
| Rosuvastatin 5-10 mg | ||
| Simvastatin 20–40 mg | ||
| Pravastatin 40-80 mg | ||
| Lovastatin 40 mg | ||
| Fluvastatin XL 80 mg | ||
| Fluvastatin 40 mg | ||
| BID Pitavastatin 2–4 mg | ||
| Low-Intensity Statin Therapy | Approximately <30% | Simvastatin 10 mg |
| Pravastatin 10–20 mg | ||
| Lovastatin 20 mg | ||
| Fluvastatin 20–40 mg | ||
| Pitavastatin 1 mg |