Atherosclerotic Cardiovascular Disease (ASCVD)
Atherosclerotic Cardiovascular Disease (ASCVD)
Clinical Overview
ASCVD includes coronary, cerebrovascular, and peripheral artery disease (PAD) caused by atherosclerosis. This page focuses on coronary ASCVD and lipid management, from identifying risk before a first event to reducing the risk of recurrence.
Atherosclerosis develops as cholesterol-containing particles accumulate in artery walls and inflammation contributes to plaque growth. Plaque can limit blood flow, while plaque disruption can trigger thrombosis and an acute coronary event. Imaging may identify subclinical disease before symptoms develop.
Established clinical ASCVD and subclinical atherosclerosis call for different approaches to risk assessment, treatment intensity, and lipid goals.
Coronary artery disease
Atherosclerotic coronary artery disease (CAD) may present with angina or exertional dyspnea or remain asymptomatic. Plaque disruption and thrombosis can cause acute coronary syndrome (ACS), including unstable angina and myocardial infarction (MI).
Plaque detected on imaging shouldn’t automatically be treated as equivalent to prior MI or coronary revascularization. Its extent and the patient’s overall risk help determine the appropriate preventive treatment.
Cholesterol and cardiovascular risk
LDL cholesterol (LDL-C) is a major treatment target, but it doesn’t tell the whole risk story. Non–HDL cholesterol reflects cholesterol carried by all atherogenic particles. Apolipoprotein B (ApoB) and lipoprotein(a), or Lp(a), can help clarify risk beyond LDL-C.
Treatment intensity depends on the patient’s clinical history, overall risk, and the LDL-C reduction needed to reach their goal.
Resources & References
Guidelines
Full guidelines, practical tools, and supporting publications are listed separately below.
- 2026 ACC/AHA Dyslipidemia Guideline
- 2023 AHA/ACC Chronic Coronary Disease Guideline
- 2025 ACC/AHA Acute Coronary Syndromes Guideline
- 2025 AHA/ACC High Blood Pressure Guideline
- ADA Standards of Care in Diabetes—2026: Cardiovascular Disease and Risk Management
- 2021 AHA/ACC Chest Pain Guideline—Executive Summary
- 2019 ACC/AHA Primary Prevention Guideline—aspirin and lifestyle guidance
*For lipid management and risk estimation, use the 2026 dyslipidemia guideline rather than the older lipid recommendations in the 2019 prevention guideline.
Additional guidance & clinical tools
- 2026 Dyslipidemia Guideline-at-a-Glance—implementation summary
- 2026 ACC Antiplatelet Therapy Scientific Statement
- 2025 ESC/EAS Focused Update on Dyslipidaemias
- 2025 AACE Dyslipidemia Consensus Algorithm
- AHA PREVENT calculator
- Vasculearn Network Lp(a) Clinician Toolkit
- ACC Lipid Manager
- JACC Chest Pain Interactive Tool—evaluation and testing pathways
- 2022 ACC Acute Chest Pain Decision Pathway—emergency department evaluation and disposition
- ADA 2026 Pharmacologic Treatment Tables—agent-specific cardiovascular and kidney benefits
- AHA scientific statement on implementing prevention to eliminate health care inequities
References
1. Blumenthal RS, Morris PB, Gaudino M, et al. J Am Coll Cardiol. 2026;87(19):2624-2757. doi:10.1016/j.jacc.2025.11.016
2. Virani SS, Newby LK, Arnold SV, et al. J Am Coll Cardiol. 2023;82(9):833-955. doi:10.1016/j.jacc.2023.04.003
3. Rao SV, O’Donoghue ML, Ruel M, et al. J Am Coll Cardiol. 2025;85(22):2135-2237. doi:10.1016/j.jacc.2024.11.009
4. Gulati M, Levy PD, Mukherjee D, et al. J Am Coll Cardiol. 2021;78(22):2218-2261. doi:10.1016/j.jacc.2021.07.052
5. Mach F, Koskinas KC, Roeters van Lennep JE, et al. Eur Heart J. 2025;46(42):4359-4378. doi:10.1093/eurheartj/ehaf190
6. Patel SB, Belalcazar LM, Afreen S, et al. Endocr Pract. 2025;31(10):1207-1238. doi:10.1016/j.eprac.2025.07.014
7. Wiggins BS, Barac A, Benziger CP, et al. J Am Coll Cardiol. 2026;87(19):2617-2623. doi:10.1016/j.jacc.2026.02.4872
8. Lee YJ, Lee SJ, Kim JW, et al. N Engl J Med. 2026;394(14):1365-1375. doi:10.1056/NEJMoa2600283
9. Kumbhani DJ, Gibson CM, Kinlay S, et al. J Am Coll Cardiol. 2026;88(11):1284-1313. doi:10.1016/j.jacc.2026.05.037
10. Jones DW, Ferdinand KC, Taler SJ, et al. J Am Coll Cardiol. 2025;86(18):1567-1678. doi:10.1016/j.jacc.2025.05.007
11. Arnett DK, Blumenthal RS, Albert MA, et al. J Am Coll Cardiol. 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.010
12. American Diabetes Association Professional Practice Committee for Diabetes. Diabetes Care. 2026;49(suppl 1):S216-S245. doi:10.2337/dc26-S010
13. Agarwala A, Patel J, Stephens J, et al. Circulation. 2023;148(15):1183-1193. doi:10.1161/CIR.0000000000001171
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