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Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology
Open accessAbstract
Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current US prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general US clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient–clinician discussion with consideration of risk enhancing factors (eg, family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.
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“Technology-based solutions have the potential to meet these criteria.16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“However, recent evidence suggests that counseling related to risk reduction for CKM syndrome in high-risk women should start in the prenatal period and continue until the completion of postpartum follow-up visits for the mother and baby.16–18”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“This may be especially true in younger adults with CKM syndrome with accelerated CAC development due to multiple interrelated risk factors with high long-term CVD risk, indicating the need to start risk factor management early in the course of CKM syndrome.12–16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
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“The increased prevalence of albuminuria among those with these metabolic risk factors or lower eGFR warrants regular dual testing with eGFR and UACR for case finding.16,55”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“Through these mechanisms, adverse SDOH lead to CKM risk factor development.16–20”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“The landscape of obesity management has advanced considerably in recent years, with several effective strategies for supporting weight loss.16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“MBS has, to date, been shown to be superior overall in promoting long-term weight loss and reducing cardiovascular risks, morbidity, and mortality, though this may change as evidence for the benefits of GLP-1 accumulates.14–16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“Bupropion/naltrexone, phentermine/topiramate, and orlistat have all shown efficacy in improving glycemia, and the latter 2, in reducing BP.”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“However, while both classes of agents reduce MACE and CVD mortality in T2D,39,40 the mechanisms and cardiovascular benefits associated with these agents are somewhat distinct.16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“Meta-analyses of clinical trials of GLP-1 RA among the subgroup of patients with T2D and CKD have shown lower risks of declining kidney function, kidney failure, MACE, HF hospitalization, cardiovascular death, and all-cause mortality compared with placebo, regardless of SGLT2 inhibitor use.16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“The Look AHEAD trial of an intensive lifestyle intervention in patients with overweight/obesity and T2D, with and without CVD, did not demonstrate an impact of the intensive lifestyle intervention on cardiovascular events, possibly due to modest weight loss from the intervention and high statin use among controls.16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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In the citing paper
“Both agents reduce MACE and CVD mortality, with SGLT2i having a principal impact on HF events and GLP-1–based therapy on atherosclerotic events.3,16,17”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
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“However, sodium zirconium cyclosilicate may increase risk of HF events.16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“MASLD is the pathophysiologic result of ectopic fat deposition, inflammation, and insulin resistance, which are central to CKM syndrome.16,17”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“a lower eGFR, higher UACR, and higher CKD stages are associated with VTE development and worse outcomes.16–20”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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“Sleep disorders (eg, obstructive sleep apnea)16”
From 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome (2026) · cites this paper as [16]
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Self-citation
Metadata
- Authors
- Lloyd-Jones, D. M., Braun, L. T., Ndumele, C. E., Smith, S. C., Sperling, L. S., Virani, S. S., & Blumenthal, R. S.
- Venue
- Circulation
- Published
- 2019-06-18
- Volume
- 139
- Issue
- 25
- Pages
- e1162-e1177
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2900130109
- Semantic Scholar
- ded6a6f83fd3adbb4f38206ff400f0aaca65b22a
- Cited by
- 554
- References
- 94
- Citations by year
- 2026: 49 · 2025: 74 · 2024: 76 · 2023: 87 · 2022: 95 · 2021: 90 · 2020: 50 · 2019: 31
- FWCI
- 13.71
- Type
- journal article
- Language
- en
- Update notices
- correction (2019-06-17)
- Open access
- bronze
- doi.org
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipoproteins and Cardiovascular Health
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Keywords
- atherosclerotic cardiovascular disease, primary prevention, cardiovascular risk assessment, Pooled Cohort Equations, 10-year risk, shared decision-making, statin therapy, antihypertensive therapy, coronary artery calcium, risk reclassification, risk score, racial and ethnic disparities, socioeconomic status, chronic inflammation, family history (medicine), blood pressure control, cholesterol management
- MeSH terms
- Clinical Decision-Making, Adult, Age Factors, Aged, Antihypertensive Agents, Decision Support Techniques, Female, Health Status, Humans, Male, Middle Aged, Predictive Value of Tests, Primary Prevention, Risk Factors, Sex Factors, Randomized Controlled Trials as Topic, Treatment Outcome, Risk Assessment, Patient Selection, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Evidence-Based Medicine, Consensus, Atherosclerosis, Protective Factors
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