Atherosclerotic Cardiovascular Disease (ASCVD)
Atherosclerotic Cardiovascular Disease (ASCVD)
Prevention
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Prevent a first event
Support healthy behaviors at every risk level. For eligible patients, use PREVENT-ASCVD risk alongside lipid levels, comorbidities, risk enhancers, and patient preferences to guide medication decisions.
10-year PREVENT-ASCVD risk | Approach |
|---|---|
<3% low | Emphasize lifestyle; consider longer-term risk and other treatment indications. |
3% to <5% borderline | Consider lipid-lowering therapy after a personalized discussion; risk enhancers or selective CAC may help. |
5% to <10% intermediate | Discuss lipid-lowering therapy; moderate-intensity statin therapy is recommended. |
≥10% high | Use high-intensity statin therapy when treatment is initiated. |
- For borderline- or intermediate-risk patients, an LDL-C goal <100 mg/dL is reasonable
- For high-risk patients, <70 mg/dL is reasonable.
- LDL-C ≥190 mg/dL warrants treatment without calculating risk.
- Statin therapy is also recommended for primary prevention in adults aged 40–75 years with diabetes or stage 3 or 4 CKD, and in those with HIV on stable antiretroviral therapy, regardless of calculated ASCVD risk. Account for drug interactions and individual contraindications.
Reduce risk beyond LDL-C
- Pair lipid treatment with tobacco cessation, blood pressure control, and support for nutrition and physical activity.
- In patients with type 2 diabetes and ASCVD, select a glucagon-like peptide-1 (GLP-1) receptor agonist and/or sodium-glucose cotransporter-2 (SGLT2) inhibitor with demonstrated cardiovascular benefit, regardless of A1c.
- GLP-1 receptor agonists: Liraglutide, dulaglutide, and semaglutide (injectable or oral) reduce major adverse cardiovascular events.
- SGLT2 inhibitors: Empagliflozin and canagliflozin reduce major adverse cardiovascular events; dapagliflozin’s cardiovascular benefit is primarily in reducing heart failure events.
- Heart failure, CKD, tolerability, and access should inform selection.
Don’t default to aspirin for primary prevention
Aspirin is no longer routine primary prevention therapy. Its use requires an individualized assessment of cardiovascular benefit and bleeding risk.
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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