Treatment Guideline Chart
Cardiovascular disease (CVD) development is closely related to lifestyle characteristics and associated risk factors.
There is overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a CV event.
Primary CVD prevention is aimed at the healthy population and population at risk (with ≥1 CV risk factors) that has not had a CV event while secondary CVD prevention is instituted for those who have confirmed CVD or had a first index event.

Cardiovascular%20disease%20prevention Diagnosis


  • Atherosclerotic cardiovascular disease (ASCVD) risk assessment is essential for primary prevention
    • CVD includes coronary heart disease (CHD), heart failure, peripheral artery disease (PAD) and stroke
  • For patients 20-39 years old, traditional ASCVD risk factors may be assessed at least every 4-6 years 
  • Patients ≥40 years old should be evaluated for the absolute risk of CVD at every routine physician visit
  • Patients 20-39 years old and those between 40-59 years old with low 10-year ASCVD risk (<7.5%) may be assessed for long-term/lifetime risk
Coronary Risk Charts for Determination of CVD Risk 
  • Age, gender, smoking status, diabetes mellitus (DM), blood pressure (BP), and lipid levels are used to determine the CVD risk
  • Overall CVD risk is more important than the presence or absence of specific risk factors 
  • Risk assessment tools that may be used to estimate CVD risk for patients who have not experienced symptomatic CVD or other atherosclerotic diseases include Framingham Risk Assessment Tool, Multi-Ethnic Study of Atherosclerosis (MESA) 10-year ASCVD risk with coronary artery calcification calculator, Systematic Coronary Risk Estimation (SCORE), Reynold’s Risk Score, and United Kingdom Prospective Diabetes Study (UKPDS) risk engine in individuals with type 2 DM
  • After estimating the 10-year fatal and non-fatal CVD risk in apparently healthy individuals, the following should be considered: Risk modifiers (ethnicity, family history, genetics, frailty, body composition, psychosocial factors, socioeconomic determinants, environmental factors, blood or urine biomarkers, imaging findings), lifetime risk and treatment benefit, polypharmacy and patient preferences

Risk Stratification

Major Risk Factors

  • Age (men ≥45 years; women ≥55 years)
  • Cigarette smoking
  • Apolipoprotein-B-containing lipoproteins (most abundant of which is LDL) 
    • Primary hypercholesterolemia (LDL-C 160-189 mg/dL [4.1-4.8 mmol/L]; non-HDL-C 190-219 mg/dL [4.9-5.6 mmol/L]) 
  • Increased serum total cholesterol level
  • Chronic kidney disease (CKD)
  • Diabetes mellitus
    • For individuals with high HDL-C (>60 mg/dL), subtract 1 risk factor from the total
    • History of gestational diabetes in women
  • Hypertension (elevated BP or on antihypertensive medication)
    • History of preeclampsia or pregnancy-induced hypertension in women
  • Metabolic syndrome 
  • Family history of premature ASCVD (male first-degree relative <55 years; female first-degree relative <65 years)

Additional Risk Factors

  • Dyslipidemic triad (hypertriglyceridemia; low HDL-C; and an excess of small, dense LDL-C)
  • Fasting/postprandial hypertriglyceridemia
  • Family history of hyperlipidemia
  • Obesity, abdominal obesity
  • Elevated apo B
  • Elevated LDL particle number
  • Elevated small dense LDL-C
  • Polycystic ovarian syndrome (PCOS) in women
  • History of premature menopause
  • South Asian ancestry 

Nontraditional Risk Factors

  • Elevated lipoprotein (a)
  • Elevated clotting factors
  • Elevated inflammation markers, eg high-sensitivity C-reactive protein (CRP)
  • Chronic inflammatory conditions, eg HIV, psoriasis, rheumatoid arthritis
  • Elevated triglyceride (TG)-rich remnants
  • Elevated homocysteine levels
  • Apo E4 isoform
  • Elevated uric acid
  • Ankle-brachial index <0.9 

Conditions Considered as CHD Risk Equivalents:

  • Type 2 DM
    • There was insufficient evidence to support type 1 DM as a CHD risk equivalent, although type 1 DM with proteinuria may increase the risk for ischemic cardiovascular disease
  • Patients with other forms of symptomatic atherosclerotic disease, such as PAD, abdominal aortic aneurysm, and symptomatic carotid artery disease
  • Large-vessel atherosclerotic ischemic stroke
  • Framingham Heart Score risk ≥20%

Note that CVD risk may be higher than indicated in the coronary risk chart in the following:

  • Patients approaching the next age, BP or cholesterol category
  • Sedentary or obese patients
  • Those with family history of premature CHD or stroke in a first-degree relative (male <55 years; female <65 years)
  • Patients with low HDL-C or high TG
  • Patients with DM or impaired glucose tolerance
  • Those already on antihypertensive therapy
  • Patients with evidence of preclinical atherosclerosis

Risk Category ACC/AHA 2019   CCS 2021 ESC 2021
 10-Year ASCVD Risk1  FRS2 Apparently Healthy Individuals3   Patients with Risk Factors  
Very High Risk Not applicable Not applicable • <50 years: ≥7.5%
• 50-69 years: ≥10%
• ≥70 years: ≥15%

SCORE2-Diabetes: ≥20%5
• Documented clinical ASCVD (eg previous acute myocardial infarction, acute coronary syndrome, coronary revascularization and other arterial revascularization procedures, TIA and stroke, aortic aneurysm and PAD) or unequivocally documented ASCVD finding (eg significant plaque) on imaging that does not include some increase in continuous imaging parameters (eg intima-media thickness of the carotid artery) 
• T2DM with established ASCVD and/or severe target organ damage (TOD)4
• Without diabetes or ASCVD but with severe CKD (eGFR <30 mL/min/1.73 m2) or eGFR 30-44 mL/min/1.73 m2 and albumin-to-creatinine ratio (ACR) >30
High Risk ≥20%  ≥20% • <50 years: 2.5-<7.5%
• 50-69 years: 5-<10%
• ≥70 years: 7.5-<15%

• T2DM without ASCVD and/or severe TOD with moderate risk criteria not met4
• Without diabetes or ASCVD but with moderate CKD (eGFR 30-44 mL/min/1.73 m2) and ACR <30 or eGFR 45-59 mL/min/1.73 m2 and ACR 30-300 or eGFR ≥60 mL/min/1.73 m2 and ACR >300
• Familial hypercholesterolemia associated with markedly increased levels of cholesterol
Moderate Risk Not applicable Not applicable • <50 years: <2.5%
• 50-69 years: <5%
• ≥70 years: <7.5%

• Patients with <10 years of well-controlled T2DM without TOD or other ASCVD risk factors4 
Intermediate Risk 7.5-<20%  10-19.9% Not applicable
Borderline Risk 5-<7.5%  Not applicable Not applicable
Low Risk <5%  <10% • <50 years: <2.5%
• 50-69 years: <5%
• ≥70 years: <7.5%

SCORE2-Diabetes: <5%5
T2DM = Type 2 Diabetes Mellitus
1ASCVD risk estimator (!/calculate/estimator/) estimates the 10-year ASCVD risk for asymptomatic individuals 40-75 years old. 
2Based on the Framingham Risk Score (FRS) screening every 5 years for ages 40-75 years.
3Based on SCORE2 and SCORE2-Older Persons (SCORE2-OP); can be accessed in the ESC CVD Risk Calculation app (including SCORE2-Diabetes).  
SCORE2 estimates the 10-year risk of fatal and non-fatal CVD events (eg stroke, MI) in apparently healthy individuals 40-69 years old with risk factors that are not treated or have been stable for several years.   
SCORE2-OP estimates the 5- and 10-year fatal and non-fatal CVD events (eg stroke, MI) adjusted for competing risks in apparently healthy individuals ≥70 years old.  
4Patients >40 years old with type 1 DM may also be classified according to these criteria.
5Based on the 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes.
  • Arnett DK, Blumenthal RS, Albert MA, 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.
  • Pearson GJ, Thanassoulis G, Anderson TJ, et al. 2021 Canadian Cardiovascular Society (CCS) Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Can J Cardiol. 2021.
  • Visseren FLJ, Mach F, Smulders YM, et al; ESC National Cardiac Societies, ESC Scientific Document Group. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021.
  • Marx N, Federici M, Schutt K, et al. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023.
  • History

    • Conventional risk factors include age, smoking, sedentary lifestyle, unhealthy diet (eg salt and fat intake), overweight/obesity, hypertension, DM, hypercholesterolemia or combination of clinical entities like metabolic syndrome
      • Patients with DM should be screened for severe TOD and ASCVD symptoms
    • Current symptoms of atherosclerosis (eg angina, intermittent claudication, myocardial infarction [MI], TIA, or stroke)
    • Personal history of polycystic ovary syndrome, gout, chronic inflammatory conditions, sexual dysfunction, kidney disease, periodontitis
    • Use of drugs known to raise BP (eg oral contraceptives, nonsteroidal anti-inflammatory drugs [NSAIDs], licorice, cocaine, amphetamine, Erythropoietin, Ciclosporin, and steroids)
    • Family history of high BP, DM, dyslipidemia, CHD, stroke, renal disease and premature CVD
      • Risk of chronic heart disease increases as number of family members with chronic heart disease increases and the younger the age at which family members develop the disease (<55 years of age in first-degree male relatives or female relatives <65 years old)
    • Personal, psychosocial, occupational and environmental factors that can influence long-term care (eg depression, anxiety, type D personality, lack of social support, social isolation, and stressful conditions at work)
    • Alcohol consumption

    Physical Examination

    • BP, pulse rate, ankle-brachial index
    • Height, weight, waist circumference
      • Calculate body mass index (BMI) by dividing patient’s weight (kg) by the square of the height (m2)
    • Comprehensive physical examination
      • CV: Heart size, apex beat displacement, signs of heart failure, disease in the carotid, renal and peripheral arteries, coarctation of aorta
      • Lungs: Signs of congestion or lung disease
      • Abdomen: Bruits, enlarged kidneys, liver and other masses
      • Eyes: Optic fundi, corneal arcus, xanthelasma 
      • Central Nervous System (CNS): Evidence of CVD and complications of diabetes (ie neuropathy)
      • Skin: Tendon xanthomas 
    • Examination for features of secondary hypertension (pheochromocytoma, Cushing’s syndrome)

    Diagnostic Tests

    • May include a complete blood count (CBC), fasting blood glucose and/or HbA1c, serum lipids (total cholesterol [TC], low density lipoprotein-cholesterol [LDL-C], high density lipoprotein-cholesterol [HDL-C] and triglycerides [TG]), sodium, potassium, uric acid, creatinine and estimated glomerular filtration rate (eGFR), liver function tests (LFTs), urinalysis, 12-lead ECG
    • A chest X-ray may help in the detection of cardiomegaly and early pulmonary findings of heart failure

    The following should be performed based on patient’s risk for dyslipidemia and diabetes (at least every 5 years or more frequent if risk factors are present)

    • Fasting serum lipoprotein profile
      • If patient has not fasted prior to lipid profile: TC and HDL-C can still be measured
    • Fasting blood glucose
    • High-sensitivity C-reactive protein may be considered in intermediate- to high-risk patients with LDL-C levels of <130 mg/dL that needs further stratification
    • The following are not recommended for routine use but may be considered in select patients: Homocysteine level and lipoprotein (a) level, DNA-based tests, any serological or urinary biomarkers


    • Coronary artery calcification (CAC) measurement and carotid intima-media thickness (CIMT) test may help in choosing best treatment strategy for patients
      • CAC scoring is the best imaging modality to improve stratification of CVD risk
    • Echocardiography may be performed in patients with breathlessness or hypertension
    • Exercise stress testing may be considered in the CV assessment of an asymptomatic individual with an interpretable resting ECG, a high CAD pre-test likelihood, and an intermediate to high CV risk
    • Ultrasound screening for abdominal aortic aneurysm may be performed in asymptomatic men 60-80 years old
    Editor's Recommendations
    Special Reports