Systematic Coronary Risk Evaluation 2 (SCORE2)

• Use the risk estimate together with clinical judgement to define preventive intensity and interpret results within the broader clinical context.   
  
  • In younger individuals, modest absolute 10-year risk may still reflect substantial lifetime risk. 
  • In older adults, competing noncardiovascular mortality may attenuate treatment benefit. 
• Reassess risk periodically, especially after major changes in smoking status, blood pressure, or lipid profile. 

SCORE2 is intended to support cardiovascular risk estimation and shared decision-making; this summary does not provide independent treatment recommendations.  

• Management strategies should be linked to estimated absolute cardiovascular risk. 
• Higher SCORE2 categories warrant progressively intensive LDL-cholesterol lowering, stricter blood-pressure control, and structured lifestyle intervention. 
• Shared decision-making is recommended when considering pharmacologic prevention in intermediate-risk individuals.  
• Management decisions should be guided by the most recent ESC/EAS dyslipidemia and ESC prevention guidelines, integrating clinical judgement, comorbidities, frailty, life expectancy, expected treatment benefit, patient preferences, and risk modifiers.

RISK CATEGORIES

The following are defined by the 2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias.  

• Very high risk includes ≥1 of the following: 
  
  • Established ASCVD* (clinical or imaging), severe CKD (eGFR <30), diabetes with target-organ damage or ≥3 major risk factors, or FH with another major risk factor.
  • SCORE2 ≥20%.  
• High risk includes ≥1 of the following:  
  
  • Markedly elevated single risk factors (LDL-C ≥4.9 mmol/L [190 mg/dL], total cholesterol >8 mmol/L, or BP ≥180/110 mmHg), moderate CKD (eGFR 30–59), FH without other major risk factors, or diabetes ≥10 years or with another risk factor.
  • SCORE2 10%–<20%.  
• Moderate risk includes ≥1 of the following:  
  
  • Young patients with diabetes and without additional risk factors (T1DM <35 years or T2DM <50 years, duration <10 years). 
  • SCORE2 2%–<10%.  
• Low risk: SCORE2 <2%.  

*ASCVD includes: 

• Prior acute coronary syndrome (ACS)/MI.
• Coronary revascularization.
• Stroke/transient ischemic attack (TIA).
• Peripheral arterial disease.
• Unequivocal atherosclerosis on imaging (e.g., >50% stenosis or CAC >300).

PHARMACOLOGIC MANAGMENT

2025 lipid-update recommends pharmacologic LDL-C lowering (class I recommendation) after lifestyle optimization in:  

• Very high risk: LDL-C ≥1.8 mmol/L (≥70 mg/dL).  
• High risk: LDL-C ≥2.6 mmol/L (≥100 mg/dL).  

It should be considered (class IIa recommendation) in:  

• Very high risk: LDL-C 1.4–<1.8 mmol/L (55–<70 mg/dL).  
• High risk: LDL-C 1.8–<2.6 mmol/L (70–<100 mg/dL).  
• Moderate risk: LDL-C 2.6–<4.9 mmol/L (100–<190 mg/dL).
• Low risk: LDL-C 3.0–<4.9 mmol/L (116–<190 mg/dL).

THERAPEUTIC APPROACH  

• Begin with lifestyle modification for all patients.  
• First-line pharmacotherapy is high-intensity statin therapy.  
• If LDL-C goals are not reached:  
  
  • Add ezetimibe.  
  • Add a PCSK9 inhibitor (e.g., alirocumab, evolocumab) for persistent elevation in high- or very high-risk patients.  
• Consider bempedoic acid, particularly in statin-intolerant patients.   
• Refine borderline decisions using risk modifiers (patients near treatment thresholds may warrant upward risk reclassification if they have any of the following): 
  
  • Coronary artery calcium (CAC)/plaque imaging abnormalities.
  • Elevated lipoprotein(a) (Lp[a]).
  • Elevated high sensitivity C-reactive protein (hs-CRP).
  • Family history of premature CVD.
  • CKD.
  • Chronic inflammatory disease.
  • Obesity.
  • Inactivity.
  • Psychosocial stress.
  • Social deprivation.
  • High-risk ethnicity.