A Systematic Examination of the 2013 Pooled Cohort Risk Assessment Tool for Atherosclerotic Cardiovascular Disease

Study Questions:

Using the Pooled Cohort Equations, what are the risk factor levels required to exceed risk thresholds outlined in new cholesterol guidelines, with emphasis on age, race, and sex?


The 2013 American College of Cardiology/American Heart Association updated cholesterol guidelines recommend using Pooled Cohort Equations to estimate 10-year absolute risk for atherosclerotic cardiovascular disease (ASCVD) in primary prevention. The authors entered continuous risk factor levels in isolation and combination with the risk tool, and observed predicted risk output patterns. They used the 10-year ASCVD risk threshold of ≥7.5% as a clinically relevant risk threshold.


A hypothetical man or woman can reach clinically relevant risk thresholds throughout the eligible age spectrum of 40-79 years, depending on the associated risk factor burden in all race-sex groups. Age continues to be a major determinant of 10-year ASCVD risk for both men and women. Compared to the previous risk assessment tool used in cholesterol guidelines, the inclusion of a stroke endpoint and use of race-specific coefficients permit identification of at-risk African Americans and non-Hispanic White women at much younger ages and lower risk factor levels.


The data provide context of specific risk factor levels and groups of individuals who are likely to have 10-year ASCVD risk estimates ≥7.5%. Age continues to be a major driver of risk, highlighting the importance of the clinician–patient discussion prior to initiating statin therapy.


The needed value of including population data from different ethnic groups by sex and stroke as an endpoint is emphasized by the following: If ‘modestly abnormal’ risk factor levels are entered (indicated by total cholesterol of 240 mg/dl; high-density lipoprotein cholesterol of 37 mg/dl for a non-Hispanic White man, 43 mg/dl for an African-American man, 48 mg/dl for a non-Hispanic White woman, or 49 mg/dl for an African-American woman; and untreated systolic blood pressure of 150 mm Hg) and no smoking or diabetes, 10-year ASCVD risk ≥7.5% is reached at the age of 50 years for both a non-Hispanic White man and an African-American man, age 65 years for a non-Hispanic White woman, and age 60 years for an African-American woman.

Clinical Topics: Dyslipidemia, Prevention, Lipid Metabolism, Smoking

Keywords: Ethnic Groups, Stroke, European Continental Ancestry Group, Blood Pressure, Risk Factors, Hispanic Americans, Cost of Illness, Smoking, Primary Prevention, Cardiovascular Diseases, Lipoproteins, HDL, Diabetes Mellitus

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