Comparison of principal components of guidelines for management of cardiovascular disease risk in the USA, Europe and UK
| ACC/AHA | ESC/EAS | NICE | ||||||
|---|---|---|---|---|---|---|---|---|
| Initiation threshold for intervention | LDL-C >4.9 mmol/L
ASCVD risk >7.5% DM and age 40–75 years | Total CVD risk, score % | LDL-C, mmol/L | |||||
| Primary prevention | Low risk, >1 | ≥4.9 | Primary prevention | >10% CVD risk or FH | ||||
| Borderline risk, >1 to <5 | ≥4.9 | |||||||
| Moderate risk, >5 to <10 | ≥2.6 | |||||||
| High risk, >10 | ≥1.8 | |||||||
| Secondary prevention | Very high-risk | ≥1.4 | Secondary prevention | All CVD including peripheral arterial disease | ||||
| Risk measures calculator system, age range and components | Pooled cohort equations (PCE) | European SCORE calculator (fatal CVD only) | QRISK2 (QRISK3) in England and Wales, ASSIGN in Scotland | |||||
| 40–75 years
Age Gender Smoking Systolic blood pressure Total cholesterol HDL-cholesterol | 40–70 years
Low-risk vs high-risk regions of Europe Age Gender Smoking Systolic blood pressure Total cholesterol | 35–75 (25–85) years
Age Gender Smoking Systolic blood pressure Total cholesterol HDL-cholesterol Deprivation Ethnicity Family history of CVD (<60 years) Treated blood pressure Atrial fibrillation CKD3 T2DM Autoimmune disease (RA) | ||||||
| Additional CVD risk factors | Family history CVD (male <55 years; female <65 years)
Metabolic syndrome Coronary Artery Calcium Score >100 Lp(a) >50 mg/dL (125 nmol/L) ApoB >130 mg/dL CRP >2 mg/L Chronic kidney disease Chronic inflammation Premature menopause High-risk race/ethnicity Persistent LDL-C >4.1 mmol/L or triglycerides >2.0 mmol/L Ankle-brachial index <0.9 | Family history CVD <55 years
Social deprivation HIV Major psychiatric disease Chronic autoimmune disease Obesity (central or morbid) Obstructive sleep apnoea Atrial fibrillation Left ventricular hypertrophy Non-alcoholic fatty liver disease Physical inactivity/psychosocial stress Carotid or femoral plaques Coronary artery calcium score >100 Ankle-brachial index <0.9 or >1.40 Carotid-femoral pulse wave velocity >10 m/s Lp(a) elevation >180 mg/dL (430 nmol/L) ApoB (see targets) Triglycerides >2.3 mmol/L CRP >2 mg/dL Albuminuria | Many added in QRISK3 (2017)
T1DM Systemic lupus erythematosus Major psychiatric disease: use of atypical antipsychotics Use of steroid therapy | |||||
| Targets for primary prevention by risk category | LDL-C mmol/L | ASCVD risk estimation, % | Goal of LDL-C reduction | SCORE, % | Target LDL-C, mmol/L | Non-HDL-C, mmol/L, and ApoB, mg/dL | No target, start moderate intensity statin eg atorvastatin 20 mg or equivalent increment for additional risk, adherence check if non-HDL-C change <40% | |
| >4.9 | Regardless of ASCVD risk | Highest intensity statin | >10 (or very high-risk) | <1.4 | <2.2 and <65 | |||
| 1.8–4.9 | High risk, >20 | Statin to reduce LDL-C, >50% | >5 to <10 | <1.8 | <2.6 and <85 | |||
| Intermediate, 7.5–20 | Statin to reduce LDL-C, 30–40% | 1–5 | <2.6 | <3.4 and <100 | ||||
| Borderline, 5–7.5 | Discuss moderate dose statin | <1 | <3.0 | |||||
| Targets for secondary prevention | LDL-C <1.8 mmol/L
Very-high risk group LDL-C <1.4 mmol/L | LDL <1.4 mmol/L
2nd ASCVD event LDL-C <1.0 mmol/L | Non-HDL-C <2.2 mmol/L and ApoB <65 mg/dL | No target, high dose high intensity statin eg atorvastatin 80 mg and ezetimibe (some cases), adherence check if non-HDL-C change <40% | ||||
| Definition of very high-risk patients | LDL-C >4.9 mmol/L
ASCVD risk >20% Previous CVD | ASCVD, either clinical or diagnosed on imaging
DM with target organ damage or >3 major risk factors or T1DM (>20 years duration) Severe CKD (CKD4) SCORE >10% FH with ASCVD or another risk factor | n/a | |||||
| Criteria for use of PCSK9-inhibitor | FH or recurrent ACS (very high risk)
LDL-C >2.5 mmol/L | FH or recurrent ACS (very high risk) Failure to reach LDL-C goal (based on risk) on maximal statin and ezetimibe | Primary prevention: FH with LDL-C >5 mmol/L
Secondary prevention: CVD with LDL-C >4 mmol/L with monovascular disease, CVD with LDL-C >3.5 mmol/L with multivascular/recurrent disease | |||||
ACC = American College of Cardiology; ACS = acute coronary syndrome; AHA = American Heart Association; ApoB = apolipoprotein B; ASCVD = atherosclerotic cardiovascular disease; CVD = cardiovascular disease; CKD = chronic kidney disease; CRP = C-reactive protein; DM = diabetes mellitus; EAS = European Atherosclerosis Society; ESC = European Society of Cardiology; FH = familial hypercholesterolaemia; LDL-C = low-density lipoprotein cholesterol; Lp(a) = Lipoprotein (a); non-HDL-C = non-high-density lipoprotein cholesterol; PCSK9-inhibitor = proprotein convertase subtilisin kexin 9 inhibitor; RA = rheumatoid arthritis; SCORE = Systematic Coronary Risk Estimation chart for European populations; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus.