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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.

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Step 1: High-Risk Criteria: History of ASCVD

History of ASCVD

History of acute coronary syndrome (ACS), myocardial infarction (MI), stable angina, coronary/other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease (PAD) from atherosclerosis

Result:

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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.

See Section 5 of the relevant 2018 American guidelines for a discussion and recommendations about statin safety. Also see Table 3 of the same guidelines for summary of grossly equivalent statin intensities for different statins at different doses.

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

  • Family history of premature ASCVD.

  • Persistently elevated LDL-C levels at or above 160 mg/dL (4.1 mmol/L).

  • Chronic kidney disease.

  • Metabolic syndrome.

  • Conditions specific to women (e.g. preeclampsia, premature menopause).

  • Inflammatory diseases (especially rheumatoid arthritis, psoriasis, HIV).

  • Ethnicity (e.g. South Asian ethnicity).

  • Persistently elevated triglycerides levels at or above 175 mg/dL (2.0 mmol/L).

  • And in selected individuals if measured:

    •  High-sensitivity C-reactive protein (hsCRP) levels at or above 2.0 mg/L.

    • Lp(a) levels above 50 mg/dL (125 nmol/L).

    • ApoB at or above 130 mg/dL.

    • 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.
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