A systematic examination of the 2013 ACC/AHA pooled cohort risk assessment tool for atherosclerotic cardiovascular disease

BACKGROUND The 2013 American College of Cardiology/American Heart Association updated cholesterol guidelines recommend the use of Pooled Cohort Equations to estimate 10-year absolute risk for atherosclerotic cardiovascular disease (ASCVD) in primary prevention. OBJECTIVES This study sought to systematically examine the Pooled Cohort Equations to determine risk factor levels required to exceed risk thresholds outlined in new cholesterol guidelines. METHODS We entered continuous risk factor levels in isolation and in specified combinations with the risk tool, and we observed predicted risk output patterns. We used the 10-year ASCVD risk threshold of ≥7.5% as a clinically relevant risk threshold. RESULTS We demonstrated that a hypothetical man or woman can reach clinically relevant risk thresholds throughout the eligible age spectrum of 40 to 79 years of age, depending on the associated risk factor burden in all race-sex groups. Age continues to be a major determinant of 10-year ASCVD risk for both men and women. Compared with the previous risk assessment tool used in cholesterol guidelines, the inclusion of a stroke endpoint and use of race-specific coefficients permit identification of at-risk African Americans and non-Hispanic white women at much younger ages and lower risk factor levels. CONCLUSIONS These data provide context of specific risk factor levels and groups of individuals who are likely to have 10-year ASCVD risk estimates ≥7.5%. Age continues to be a major driver of risk, which highlights the importance of the clinician-patient discussion before statin therapy is initiated.