Table 1.

Comparison of principal components of guidelines for management of cardiovascular disease risk in the USA, Europe and UK

Initiation threshold for interventionLDL-C >4.9 mmol/L
ASCVD risk >7.5%
DM and age 40–75 years
Total CVD risk, score %LDL-C, mmol/L
Primary preventionLow risk, >1≥4.9Primary 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 preventionVery high-risk≥1.4Secondary preventionAll CVD including peripheral arterial disease
Risk measures calculator system, age range and componentsPooled cohort equations (PCE)European SCORE calculator (fatal CVD only)QRISK2 (QRISK3) in England and Wales, ASSIGN in Scotland
40–75 years
Systolic blood pressure
Total cholesterol
40–70 years
Low-risk vs high-risk regions of Europe
Systolic blood pressure
Total cholesterol
35–75 (25–85) years
Systolic blood pressure
Total cholesterol
Family history of CVD (<60 years)
Treated blood pressure
Atrial fibrillation
Autoimmune disease (RA)
Additional CVD risk factorsFamily 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
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
Many added in QRISK3 (2017)
Systemic lupus erythematosus
Major psychiatric disease: use of atypical antipsychotics
Use of steroid therapy
Targets for primary prevention by risk categoryLDL-C mmol/LASCVD risk estimation, %Goal of LDL-C reductionSCORE, %Target LDL-C, mmol/LNon-HDL-C, mmol/L, and ApoB, mg/dLNo target, start moderate intensity statin eg atorvastatin 20 mg or equivalent increment for additional risk, adherence check if non-HDL-C change <40%
>4.9Regardless of ASCVD riskHighest intensity statin>10 (or very high-risk)<1.4<2.2 and <65
1.8–4.9High risk, >20Statin to reduce LDL-C, >50%>5 to <10<1.8<2.6 and <85
Intermediate, 7.5–20Statin to reduce LDL-C, 30–40%1–5<2.6<3.4 and <100
Borderline, 5–7.5Discuss moderate dose statin<1<3.0
Targets for secondary preventionLDL-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/dLNo 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 patientsLDL-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
Criteria for use of PCSK9-inhibitorFH 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.