ASCVD Risk Stratification Series (Part 2/3): Using Risk Scores & Enhancers Without Getting Lost in Them [Pre-2026 Guidelines]

Note: This episode reflects pre-2026 dyslipidemia guidelines. Some recommendations may no longer align with current guidelines. 

ASCVD risk stratification gets messy fast—especially when calculators, risk enhancers, and coronary calcium scores all compete for attention. In Part 2 of the LipidCurious ASCVD Risk Stratification mini-series, we focus on how to use these tools without overcomplicating primary prevention or getting lost in the details.

In this episode, we cover:

1. A practical, age-first framework for approaching primary prevention
2. How to use ASCVD risk calculators, risk enhancers, and coronary calcium score—and when not to
3. How to apply this framework consistently in real-world clinical practice

Bonus: Two quick cases—including one where guidelines don’t fit perfectly—and a short, actionable challenge you can start using immediately in clinic.

Join the Learn at Pinnacle app ⁠to earn FREE CE Credit for listening to this episode! 

Disclaimer: This podcast is intended for educational purposes for clinicians and healthcare professionals. It does not provide medical advice, establish a physician–patient relationship, or replace individualized clinical judgment. The opinions expressed are those of the creator and do not represent the views of any affiliated institutions or organizations. 

Transcript

ASCVD Risk Stratification Series (Part 2 of 3): Using Risk Scores & Enhancers Without Getting Lost in Them [Pre-2026 Guidelines]

Note: This episode reflects pre-2026 dyslipidemia guidelines. Some recommendations may no longer align with current guidelines. 

Hi everyone.
Welcome back to LipidCurious—an educational platform focused on simplifying lipid management for clinicians.

I’m your host, Dr. Vishnu Priya Pulipati, a board-certified Endocrinologist and Lipidologist.

In Part 1 of this series, we discussed how to approach ASCVD risk before opening a risk calculator. Today, we’re building on that foundation. If you haven’t listened to Part 1 yet, I strongly recommend doing that first so this episode will make much more sense.

In this episode, lets focus on:

1. How to approach primary prevention
2. How to utilize ASCVD risk calculators, risk enhancers & Coronary calcium score
3. How to apply what we learnt so far in clinical practice

Alright, let’s get started

We start ASCVD risk stratification with three key questions:

1. Is there clinical ASCVD?
2. Is the LDL-C ≥190 mg/dL?
3. Does the individual have diabetes mellitus?

If the answer is yes to any of these, we’re already thinking about treatment.

If the answer is no to all three, that’s where primary prevention begins.

How to Approach Primary Prevention

Start with looking at AGE.

Children (0–19): High-intensity statin only if familial hypercholesterolemia.

Young adults (20–39): Consider statins if LDL-C >160 mg/dL and a family history of premature ASCVD. If needing statin, use lifetime ASCVD risk to guide intensity. Lifetime risk >39% = high risk.

Middle-aged adults (40–75): This is where risk calculators, risk enhancers and coronary calcium scoring matter—we’ll cover that next.

Older adults (>75): Individualize therapy. Consider moderate-intensity statin if LDL-C 70–189 mg/dL. In select patients ages 75–80, coronary calcium scoring may help when the decision to start or continue a statin is uncertain. Discontinue statins when risks outweigh benefits—frailty, functional decline, or limited life expectancy.

Choosing an ASCVD Risk Calculator

For adults 40–75 years, risk calculators can help guide treatment decisions.
 There are many tools, but today we’ll focus on two that matter most clinically:

PREVENT Calculator

Estimates 10- and 30-year risk of total CVD, ASCVD, and heart failure. Derived from >6.5 million U.S. adults. Used in adults 30–79 years without known CVD

Do NOT use PREVENT if the patient has: 

• Known cardiovascular disease
• Severe subclinical disease (LVEF <40%, CAC ≥300)
• Advanced kidney disease
• Limited life expectancy

What makes PREVENT different?

• No race variable. And it reinforces that race is not the cause of disease.
• Includes kidney markers (eGFR, ACR), A1C, and social factors
• More comprehensive and better calibrated for diverse populations

So why not use it for treatment decisions yet?
 Because we don’t have clear guidance on what to do with the results.
 For now, PREVENT is best used to support clinician–patient discussions.

Pooled Cohort Equations (PCE)

• Estimates risk of MI, stroke, or cardiovascular death
• Validated for: African American and non-Hispanic White men and women

Key limitations:

• Not applicable in atrial fibrillation or age >79
• Underestimates risk in American Indian, South Asian, and Puerto Rican patients
• Overestimates risk in East Asian and Mexican American populations

When we use the Pooled Cohort Equations, we get:

• Lifetime ASCVD risk for ages 20–59: High risk is >39%
•  10-year ASCVD risk for ages 40–79

For 10-year risk, remember three numbers: 5 – 7.5 – 20

• <5% → Low risk
• 5–7.5% → Borderline risk
• 7.5–20% → Intermediate risk
• >20% → High risk

Low risk: no treatment. High risk: offer high-intensity statin. Easy. The gray zone is borderline and intermediate risk—this is where risk enhancers matter.

• Borderline risk + risk enhancer: start a conversation about a moderate-intensity statin
• Intermediate risk + risk enhancer: favor starting a moderate-intensity statin
   If the patient is hesitant, consider coronary calcium scoring

Lets look at ASCVD Risk Enhancers (How I Remember Them)

Instead of memorizing a table, I think about ASCVD risk enhancers during routine history taking—age, comorbidities, pregnancy history, family background, habits, and a few key labs.
 If you ask these questions consistently, you don’t need a guideline table.
 EMR dot phrases help. Repetition helps even more.

When ASCVD risk is borderline or intermediate, I run a quick mental checklist.
 Remember the mnemonic: HEAD-to-LABS.

H – History (medical + OB)

• Hypertension
• Chronic kidney disease
• Metabolic syndrome, obesity, PCOS
• Chronic inflammatory disease (RA, psoriasis, HIV)
• Preeclampsia or premature menopause

E – Ethnicity & family

• Premature ASCVD
• South Asian ancestry

A – Age

• Age >65

D – Daily habits

• Smoking

L – Lipids

• LDL-C persistently >160 mg/dL
• Triglycerides persistently >175 mg/dL
• Low HDL-C

A – Advanced markers

• Elevated Lp(a)
• ApoB >130 mg/dL
• hsCRP >2 mg/L

B – Blood flow

• ABI <0.9

S – Silent disease

• Metabolic liver disease (not always listed in guidelines, but clinically important)

If I hear yes to any of these, risk enhancers are present.

Coronary Calcium Score or CAC: The Tie-Breaker

If a patient is >40 years old, has borderline or intermediate ASCVD risk, and the decision to start therapy feels uncertain—or the patient is hesitant—coronary calcium scoring can help.

Be mindful: CAC has limited utility in:

• Active smokers
• Patients with diabetes
• Strong family history of premature ASCVD
• Chronic inflammatory disease
• Patients already on statins

CAC reflects calcified plaque, not total atherosclerotic burden. So: Statins can increase CAC density while reducing events. CAC = 0 does not mean zero risk, especially in higher-risk biology

Interpreting CAC

• CAC = 0 (without the caveats above)
  → No statin
  → Repeat in 5–10 years
• CAC 1–99
   → Favors statin therapy
   → Repeat in 3–5 years
• CAC ≥100 or ≥75th percentile
   → High-intensity statin
   → Low-dose aspirin may be considered, depending on bleeding risk

Putting It All Together: Case 1

A 42-year-old African American woman presents for a wellness visit.
 History of hypertension on amlodipine. Smokes half a pack per day. BMI 24.
 BP 140/90. Fasting blood tests showed eGFR 52. HDL-C 45. TG 200 mg/dL, LDL-C 135.

I know there are a lot of data points here but let’s not get distracted. Let’s stick to our framework.

• Already has ASCVD? No.
 • LDL >190? No.
 • Diabetes? No.

Ok, primary prevention. She’s 42—so we calculate PCE.
 Her 10-year ASCVD risk is 9.5% (remember 5, 7.5, 20)—so 7.5 to 20 is intermediate risk.

Does she have risk enhancers? Yes! HTN, smoking, low GFR, low HDL, high TG.
 So we encouarge taking a moderate-intensity statin.

She feels well and is hesitant. We offer CAC. Her score is 120.

That tips the scale. We recommend high-intensity statin—and she agrees after discussion. Yay! 

See, You took less than 5 min for that decision

Case 2: When Guidelines Don’t Fit Perfectly

Okay, let’s take a more challenging case now—this one shows how I navigate gaps in the literature.

A 57-year-old South Asian man presents for a wellness exam. Nonsmoker. History of atrial fibrillation on anticoagulation, HTN on thiazide diuretic, mild carotid stenosis, COPD, prediabetes, BMI 38. BP 135/80 mm Hg. HDL-C 35. LDL-C 142. Lives in Oklahoma.

• Already has ASCVD? No.
 • LDL >190? No.
 • Diabetes? No.

Primary prevention. PCE doesn’t apply—atrial fibrillation was excluded. So what do we do?

We don’t give up.
 In these situations, decisions are driven by patient preference, the clinician’s prevention philosophy, and access to therapy. 

If the patient is proactive and access isn’t a barrier, my own prevention mindset is clear: I favor early LDL-C lowering. My mentors in lipidology have consistently reinforced that lower LDL-C for longer is better—so when I see meaningful ASCVD risk factors, my default is to think treatment.

Now there a couple of ways, I might approach this case

First, I use the PREVENT score to frame the conversation:
“You have about a 9% 10-year ASCVD risk and roughly a 35% 30-year risk.”
 With multiple risk factors—ethnicity, dyslipidemia, obesity, hypertension, and prediabetes—I’d offer at least a low- to moderate-intensity statin.

Second, I consider coronary calcium scoring.
A CAC score >100 would push me toward a high-intensity statin.

Take Home points

1.    Start with a consistent framework: rule out ASCVD, LDL-C ≥190, and diabetes, then approach primary prevention by age first.

2.    For ages 40–75: use PCE to estimate ASCVD risk. Among individuals with borderline or intermediate risk use risk enhancers and CAC to refine CV risk.

3.    Earlier LDL-C lowering for longer matters

Alright, here’s my challenge for you: over the next two weeks, with every patient who has a lipid panel, practice the framework we discussed today.

I’ll see you back in two weeks for the final part of this series. In Part 3, we’ll add the cherry on top: what numbers to target and which therapies to use. Once the foundation is solid, those decisions become much easier.

With the next episode, I’ll also include a single, easy-to-read visual that pulls this entire framework together.

Before I sign off, a quick note. This podcast is intended for educational purposes for clinicians and healthcare professionals. It does not provide medical advice, establish a physician patient relationship, or replace individualized clinical judgment.

Thank you for tuning in to LipidCurious. If today’s episode was helpful, consider sharing it with a colleague. You can always reach me at hello@lipidcurious.com.

Be sure to follow or subscribe so you do not miss what is coming next.

Until next time,
Stay curious and stay confident.

Signing off
 Dr. Pulipati.