The changing epidemiological landscape of cardiovascular disease (CVD) and associated risk factors has led to efforts to develop improved preventive approaches for short-term and long-term risk estimation. Over the previous half-decade, there have been important revisions to risk-assessment calculators internationally to facilitate clinical decision-making involving lifestyle counseling, use of subclinical atherosclerosis testing, and the allocation of preventive pharmacotherapies.¹

In Europe and the United States, new risk calculators have been developed for those without clinical CVD. The SCORE2 (Systematic Coronary Risk Evaluation 2) risk calculator was presented in the 2021 European Society of Cardiology (ESC) prevention guideline, and the PREVENT (AHA Predicting Risk of CVD Events) risk equation was introduced by the American Heart Association (AHA) in 2024 (Table 1).^2-5 Both the SCORE2 and PREVENT risk calculators incorporate non–high-density lipoprotein cholesterol levels within modeling, providing incrementally enhanced risk prediction for the atherosclerotic cardiovascular disease (ASCVD) outcomes of myocardial infarction and stroke.

Table 1: Components of the SCORE2 and PREVENT Risk Calculators

Additionally, the SCORE2 risk equation facilitates the calculation of low-to-moderate, high, and very-high risk across different age categories (<50 years vs. 50-69 years of age). Two iterations of the SCORE2 risk calculator have been developed for those with type 2 diabetes mellitus (T2DM; the SCORE2-Diabetes [Systematic Coronary Risk Evaluation 2–Diabetes]) and those >70 years of age (the SCORE2-OP [Systematic Coronary Risk Evaluation 2–Older Persons]).^3,6 The SCORE2-Diabetes risk calculator incorporates additional risk factors, including glycated hemoglobin (HbA1c) concentration, age at T2DM diagnosis, and estimated glomerular filtration rate (eGFR), whereas the SCORE2-OP risk calculator includes the same risk factors as the original SCORE2 calculator.

The PREVENT risk calculator was developed using a combination of observational cohort data and real-world clinical data to estimate 10-year and 30-year risk of ASCVD and separately for heart failure. Major updates include the incorporation of body mass index, eGFR, and statin therapy, as well as the removal of race from the risk equations. Additional terms including HbA1c concentration, urine albumin-to-creatinine ratio, and Social Deprivation Index (zip code) can be incorporated within the optional PREVENT models when such data are available.^4,5

Compared with the SCORE2 equations, the PREVENT equation facilitates the calculation of long-term (30-year) risk, which may be especially helpful for younger individuals. Communication of long-term risk with younger individuals may help further promote lifestyle counseling regarding: Mediterranean diet; regular, brisk physical activity; smoking cessation, when indicated; and quality sleep. Mobile health technologies may help with monitoring of lifestyle information for both patients and clinicians.

Of note, these risk calculators are derived from cohorts with distinct population characteristics. Variations in baseline risk, demographics, and region-specific CVD epidemiology between European and US cohorts highlight the need for careful consideration when applying these risk calculators across diverse populations. Ongoing efforts will help facilitate expanding risk prediction within certain subpopulations of the United States, including Hispanic and South Asian individuals.

Beyond the SCORE2 and PREVENT risk calculators, there are several investigational risk calculators. The lipoprotein(a) (Lp[a]) risk calculator is available for ASCVD risk estimation focused on individuals with elevated Lp(a) levels,⁷ which affects approximately 20% of the global population.⁸ The Lp(a) risk calculator is helpful for estimating long-term risk among individuals with elevated Lp(a) levels and for understanding how modification of low-density lipoprotein cholesterol levels and blood pressure may lower risk for those with high Lp(a) levels.⁹ Lastly, the LIPIDOGRAM Risk Score was developed with variables readily accessible in a primary-prevention setting to estimate the 5-year risk of CVD.¹⁰

In the future, it will be important to robustly test such newer risk calculators in external cohorts to facilitate clinical implementation. Considering recent analyses showing lower risk estimates using the PREVENT risk calculators compared with the Pooled Cohort Equations (PCE),^11,12 identification of precise risk thresholds can help guide the appropriate use of additional risk-assessment tools, including subclinical atherosclerosis imaging, as well as the allocation of preventive therapies. Whereas the SCORE2 risk equations have been incorporated within ESC prevention guidelines, the most optimal clinical risk thresholds for the PREVENT risk calculator are anticipated to be defined in the American College of Cardiology (ACC)/AHA guideline updates (Figure 1).

Figure 1: Comparison of CV Risk Calculators: SCORE2 and PREVENT

References

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3. Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021;42:3227-337.
4. Khan SS, Matsushita K, Sang Y, et al.; Chronic Kidney Disease Prognosis Consortium and the American Heart Association Cardiovascular-Kidney-Metabolic Science Advisory Group. Development and validation of the American Heart Association Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations. Circulation 2024;149:430-49.
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11. Minhas AMK, Virani SS, Michos ED, et al. Comparing cardiovascular risk classification of U.S. adults according to Pooled Cohort Equations and PREVENT equations: cross-sectional analysis of the National Health and Nutrition Examination Survey. Ann Intern Med 2024;177:1444-8.
12. Diao JA, Shi I, Murthy VL, et al. Projected changes in statin and antihypertensive therapy eligibility with the AHA PREVENT cardiovascular risk equations. JAMA 2024;332:989-1000.