2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

HomeCirculationVol. 140, No. 112019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUB2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Donna K. Arnett, PhD, MSPH, FAHA, Co-Chair, Roger S. Blumenthal, MD, FACC, FAHA, Co-Chair, Michelle A. Albert, MD, MPH, FAHA, Andrew B. Buroker, Esq, Zachary D. Goldberger, MD, MS, FACC, FAHA, Ellen J. Hahn, PhD, RN, Cheryl Dennison Himmelfarb, PhD, RN, ANP, FAHA, Amit Khera, MD, MSc, FACC, FAHA, Donald Lloyd-Jones, MD, SCM, FACC, FAHA, J. William McEvoy, MBBCh, MEd, MHS, Erin D. Michos, MD, MHS, FACC, FAHA, Michael D. Miedema, MD, MPH, Daniel Muñoz, MD, MPA, FACC, Sidney C. Smith Jr, MD, MACC, FAHA, Salim S. Virani, MD, PhD, FACC, FAHA, Kim A. Williams Sr, MD, MACC, FAHA, Joseph Yeboah, MD, MS, FACC, FAHA and Boback Ziaeian, MD, PhD, FACC, FAHA Donna K. ArnettDonna K. Arnett Search for more papers by this author , Roger S. BlumenthalRoger S. Blumenthal Search for more papers by this author , Michelle A. AlbertMichelle A. Albert Search for more papers by this author , Andrew B. BurokerAndrew B. Buroker Search for more papers by this author , Zachary D. GoldbergerZachary D. Goldberger Search for more papers by this author , Ellen J. HahnEllen J. Hahn Search for more papers by this author , Cheryl Dennison HimmelfarbCheryl Dennison Himmelfarb Search for more papers by this author , Amit KheraAmit Khera Search for more papers by this author , Donald Lloyd-JonesDonald Lloyd-Jones Search for more papers by this author , J. William McEvoyJ. William McEvoy Search for more papers by this author , Erin D. MichosErin D. Michos Search for more papers by this author , Michael D. MiedemaMichael D. Miedema Search for more papers by this author , Daniel MuñozDaniel Muñoz Search for more papers by this author , Sidney C. Smith JrSidney C. Smith Jr Search for more papers by this author , Salim S. ViraniSalim S. Virani Search for more papers by this author , Kim A. Williams SrKim A. Williams Sr Search for more papers by this author , Joseph YeboahJoseph Yeboah Search for more papers by this author and Boback ZiaeianBoback Ziaeian Search for more papers by this author Originally published17 Mar 2019https://doi.org/10.1161/CIR.0000000000000678Circulation. 2019;140:e596–e646is corrected byCorrection to: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice GuidelinesCorrection to: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice GuidelinesCorrection to: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice GuidelinesOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 9, 2019: Previous Version of Record March 17, 2019: Ahead of Print Table of ContentsTop 10 Take-Home Messages for the Primary Prevention of Cardiovascular Disease e597Preamble e5971. Introduction e5981.1. Methodology and Evidence Review e5991.2. Organization of the Writing Committee e5991.3. Document Review and Approval e5991.4. Scope of the Guideline e5991.5. Class of Recommendation and Level of Evidence e6001.6. Abbreviations e6012. Overarching Recommendations for ASCVD Prevention Efforts e6012.1. Patient-Centered Approaches to Comprehensive ASCVD Prevention e6012.2. Assessment of Cardiovascular Risk e6023. Lifestyle Factors Affecting Cardiovascular Risk e6053.1. Nutrition and Diet e6053.2. Exercise and Physical Activity e6074. Other Factors Affecting Cardiovascular Risk e6094.1. Adults With Overweight and Obesity e6094.2. Adults With Type 2 Diabetes Mellitus e6104.3. Adults With High Blood Cholesterol e6124.4. Adults With High Blood Pressure or Hypertension e6164.5. Treatment of Tobacco Use e6184.6. Aspirin Use e6215. Cost and Value Considerations e6226. Conclusion e623Appendix 1: Search Criteria e636Appendix 2: Author Relationships With Industry and Other Entities (Relevant) e641Appendix 3: Reviewer Relationships With Industry and Other Entities (Comprehensive) e642References e624Top 10 Take-Home Messages for the Primary Prevention of Cardiovascular DiseaseThe most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life.A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. In addition, assessing for other risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning.All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations, are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit.Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.PreambleSince 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts.Clinical practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease (CVD). The focus is on medical practice in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the goals are to improve quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most but not all circumstances and should not replace clinical judgment.Recommendations for guideline-directed management and therapy, which encompasses clinical evaluation, diagnostic testing, and both pharmacological and procedural treatments, are effective only when adopted by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision-making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.The ACC/AHA Task Force on Clinical Practice Guidelines strives to ensure that the guideline writing committee includes requisite expertise and is representative of the broader medical community by selecting experts from a broad array of backgrounds, representing different geographic regions, sexes, races, ethnicities, intellectual perspectives/biases, and scopes of clinical practice. The ACC and AHA have rigorous policies and methods to ensure that documents are developed without bias or improper influence. The complete policy on relationships with industry and other entities (RWI) can be found online.Beginning in 2017, numerous modifications to the guidelines have been and continue to be implemented to make guidelines shorter and enhance “user friendliness.” Guidelines are written and presented in a modular knowledge chunk format, in which each chunk includes a table of recommendations, a brief synopsis, recommendation-specific supportive text and, when appropriate, flow diagrams or additional tables. Hyperlinked references are provided for each modular knowledge chunk to facilitate quick access and review. More structured guidelines—including word limits (“targets”) and a web guideline supplement for useful but noncritical tables and figures—are 2 such changes. This Preamble is an abbreviated version, with the detailed version available online.Patrick T. O’Gara, MD, MACC, FAHAChair, ACC/AHA Task Force on Clinical Practice Guidelines1. IntroductionAlthough there has been substantial improvement in atherosclerotic cardiovascular disease (ASCVD) outcomes in recent decades, ASCVD remains the leading cause of morbidity and mortality globally.S1-1–S1-3 In the United States, it is also the leading cause of death for people of most racial/ethnic groups, with an estimated cost of >$200 billion annually in healthcare services, medications, and lost productivity. Much of this is attributable to suboptimal implementation of prevention strategies and uncontrolled ASCVD risk factors in many adults.S1-2Most Americans who have had a myocardial infarction (MI) had unfavorable levels of at least 1 cardiovascular risk factor before their ASCVD event.S1-4 In 2010, the AHA defined a new model of “ideal cardiovascular health,” referred to as Life’s Simple 7.S1-5 Clinicians will find the 2018 Journal of American College of Cardiology (JACC) Cardiovascular Health Promotion Series very helpful in approaching the various aspects of prevention with patients.S1-6 An increasing number of ideal cardiovascular health factors have been associated with a lower prevalence and incidence of ASCVD events, heart failure, atrial fibrillation, cancer, depression, and cognitive impairment.S1-7 Therefore, moving individuals toward ideal cardiovascular health is critically important for prevention of many important health conditions.The ACC/AHA Task Force on Clinical Practice Guidelines has commissioned this guideline to consolidate existing recommendations and various recent scientific statements, expert consensus documents, and clinical practice guidelines into a single guidance document focused on the primary prevention of ASCVD. However, this guideline also includes newly generated recommendations for aspirin use, exercise and physical activity, and tobacco use, in addition to recommendations related to team-based care, shared decision-making, and assessment of social determinants of health, to create a comprehensive yet targeted ACC/AHA guideline on the prevention of ASCVD. This guideline has been formatted in the modular chunk format to facilitate readability and future updating.Prevention strategies occur at the population level but must also engage individual adults to slow the development of ASCVD. The most important way to prevent ASCVD is to promote a healthy lifestyle throughout life. Prevention strategies must include a strong focus on lifestyle optimization (improvements in diet, physical activity, and avoidance of tobacco use and exposure to secondhand smoke) to minimize the risk of future ASCVD events.A comprehensive patient-centered approach that addresses all aspects of a patient’s lifestyle habits and estimated risk of a future ASCVD event is the first step in deciding on where there may be a need for pharmacotherapy. Even if a blood pressure (BP)–reducing medication, lipid-lowering medication, or diabetes medication is ultimately prescribed, lifestyle goals should be emphasized on a regular basis. Only when a person’s risk is sufficiently high should medications to reduce ASCVD risk be considered as part of a shared decision-making process for optimal treatment. In summary, clinicians and individuals should focus attention on living a healthy lifestyle by referring to these evidence-based recommendations to help prevent ASCVD.1.1. Methodology and Evidence ReviewThis guideline continues the ACC and AHA effort to design a comprehensive yet succinct compilation of practical guidance for the primary prevention of ASCVD and to promote optimal dissemination of information by using concise language and formatting. The recommendations listed in this guideline are evidence based and supported by an extensive evidence review. A search for literature derived from research involving human subjects, published in English, and indexed in Ovid MEDLINE, PubMed, Cochrane Library, National Institute for Health and Care Excellence (NICE), and other selected databases relevant to this guideline, was conducted between May and July 2018. For specific search terms used and years searched per section, please see Appendix 1.Randomized controlled trials (RCTs), systematic reviews of RCTs, meta-analyses, and large, United States–based, high-quality cohort studies, as well as observational studies and systematic reviews of observational studies, were evaluated for their content on the prevention of ASCVD outcomes related to the following 9 topic areas: risk assessment, diet, exercise/physical activity, obesity and weight loss, type 2 diabetes mellitus (T2DM), blood cholesterol, hypertension, smoking cessation, and aspirin use. Previous ACC/AHA guidelines, as well as US Preventive Services Task Force (USPSTF) reviews and other guidance relevant to this guideline, were also assessed. The final evidence tables included in the Online Data Supplement summarize the evidence used to formulate recommendations. References selected and published in this document are representative and not all-inclusive.Avalere Health, a healthcare advisory services firm contracted by ACC/AHA, served as the document manager for this guideline to facilitate its development process. As document manager, Avalere facilitated the deliberations of the Writing Committee and led the modified Delphi process for establishing the Class of Recommendation and the Level of Evidence. In parallel, an independent health data and epidemiology expert, Lee Ann Prebil, conducted a systematic evidence review for the key topic of exercise and physical activity and conducted targeted literature searches to support this document’s discussion of patient-centered approaches, including team-based care, shared decision-making, and assessment of social determinants of health. A targeted literature search was also conducted for this guideline’s cost and value considerations. These searches are available as downloadable Excel files.Recommendations and supportive text relevant to cardiovascular risk, blood cholesterol, and high BP were taken directly from 2 recently released ACC/AHA guidelines, the 2017 Hypertension Clinical Practice GuidelinesS1.1-1 and the 2018 Cholesterol Clinical Practice Guideline,S1.1-2 and were adapted for the present guideline, which aims to provide an overview of the primary prevention of ASCVD among adults. Recommendations that were adapted from previous publications are noted in the recommendation tables, and both the original published recommendation and the adapted version are provided in the guideline.The results of these evidence reviews were evaluated by the writing committee for incorporation into the present guideline. (See Table S1 in the Web Supplement for a list of relevant publications and statements used in support of the guideline’s recommendations.) Each topic area was assigned a primary writer, as well as a primary, and sometimes secondary, reviewer. These assignments were based on areas of particular expertise of writing committee members. All recommendations were fully reviewed and discussed among the full committee to allow for diverse perspectives and considerations for this guideline. Recommendations were then voted upon, with a modified Delphi process used to reach consensus.1.2. Organization of the Writing CommitteeThe writing committee consisted of clinicians, cardiologists, health services researchers, epidemiologists, internists, nurses, and a lay representative. The writing committee included representatives from the ACC and AHA. Appendix 2 of the present document lists writing committee members’ relevant RWI. For the purposes of full transparency, the writing committee members’ comprehensive disclosure information is available online.1.3. Document Review and ApprovalThis document was reviewed by 5 official reviewers nominated by the ACC and AHA (1 reviewer from the ACC/AHA Task Force for Practice Guidelines, 2 reviewers from the AHA, and 2 reviewers from the ACC); 3 reviewers on behalf of the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Society for Nutrition, and the American Society of Preventive Medicine; and 23 individual content reviewers. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 3). This document was approved for publication by the governing bodies of the ACC and AHA.1.4. Scope of the GuidelineThis guideline is intended to be a resource for the clinical and public health practice communities. It addresses the primary prevention of CVD in adults (≥18 years of age), focused on outcomes of ASCVD (ie, acute coronary syndromes, MI, stable or unstable angina, arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease of atherosclerotic origin), as well as heart failure and atrial fibrillation. The guideline presents recommendations to prevent CVD that are related to lifestyle factors (eg, diet and exercise or physical activity), other factors affecting CVD risk (eg, obesity, diabetes, blood cholesterol, high BP, smoking, aspirin use), patient-centered approaches (eg, team-based care, shared decision-making, assessment of social determinants of health), and considerations of the cost and value of primary prevention.1.5. Class of Recommendation and Level of EvidenceRecommendations are designated with both a Class of Recommendation (COR) and a Level of Evidence (LOE). The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The LOE rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).S1.5-1Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated August 2015)Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated August 2015)1.6. AbbreviationsAbbreviationMeaning/PhraseASCVDatherosclerotic cardiovascular diseaseAUAgatston unitsBMIbody mass indexBPblood pressureCHDcoronary heart diseaseCKDchronic kidney diseaseCVDcardiovascular diseaseDASHDietary Approaches to Stop HypertensionDBPdiastolic blood pressureDMdiabetes mellitusENDSelectronic nicotine delivery systemsFDAUS Food and Drug AdministrationGLP-1Rglucagon-like peptide-1 receptorHbA1chemoglobin A1cHDL-Chigh-density lipoprotein cholesterolHbA1chemoglobin A1cLDL-Clow-density lipoprotein cholesterolMImyocardial infarctionPCEpooled cohort equationsRCTrandomized controlled trialSBPsystolic blood pressureSGLT-2sodium-glucose cotransporter 2T2DMtype 2 diabetes mellitusUSPSTFUS Preventive Services Task Force2. Overarching Recommendations for ASCVD Prevention Efforts2.1. Patient-Centered Approaches to Comprehensive ASCVD PreventionSynopsisThis 2019 ACC/AHA Guideline on the Primary Prevention of CVD aims to promote the delivery of patient-centered care, which the writing committee felt was foundational to the guidance provided throughout. These patient-centered recommendations emphasize the importance of team-based care delivery, shared decision-making, and the evaluation of social determinants of health in ASCVD prevention efforts. These recommendations apply to all aspects of clinical practice for the primary prevention of ASCVD.Recommendation-Specific Supportive TextTeam-based care makes use of multidisciplinary health professionals to improve the quality and maintenance of ASCVD prevention. It is a multifaceted approach that supports clinical decision-making (ie, treatment algorithms), collaboration among different clinicians, and patient and family member participation to facilitate the treatment goals of patients.S2.1-26 RCTs and systematic reviews with meta-analyses demonstrated greater reduction of ASCVD risk with team-based care than with usual care in patients with hypertension, diabetes, and hyperlipidemia.S2.1-1–S2.1-14 A team-based approach to ASCVD prevention may result in significant improvements in patient outcomesS2.1-27 and often meets patient needs better than standard care, especially in low-resource settings and among vulnerable populations. In a team-based care model that compared patients enrolled in a preventive cardiology clinic staffed by advanced practice providers with a propensity-matched cohort of patients enrolled in primary care clinics, a reduction in cardiovascular risk was demonstrated through effective risk stratification and preventive management.S2.1-28 Other successful interventions that have used team-based care include telehealth monitoring, follow-up support aids, and patient education.S2.1-27Decisions about primary prevention should be collaborative between a clinician and a patient. Shared decision-making occurs when practitioners engage patients in discussions about personalized ASCVD risk estimates and their implications for the perceived benefits of preventive strategies, including lifestyle habits, goals, and medical therapies. Collaborative decisions are more likely to address potential barriers to treatment options, compared with treatment and guidance offered without patient input.S2.1-15–S2.1-18Socioeconomic inequalities are strong determinants of CVD risk internationally.S2.1-21,S2.1-24 Therefore, the clinician should tailor advice to a patient’s socioeconomic and educational status, as well as cultural, work, and home environments.S2.1-23 The Centers for Medicare & Medicaid Services has developed a screening tool to assess 5 domains of non–health-related measures that affect health outcomes: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety.S2.1-29 ASCVD prevention could benefit from such screening. ASCVD risk begins early in life, with heightened susceptibility tied to low socioeconomic status.S2.1-25 Examples of upstream social determinants of health that affect treatment adherence and ASCVD health outcomes include comorbid mental illness, lack of health literacy, exposure to adversity (eg, home/community violence, trauma exposures, safety concerns), financial strain, inadequate housing conditions, lack of food security (ie, access to affordable and nutritious food), and inadequate social support.S2.1-30 Systems of care should evaluate social determinants of health that affect care delivery for the primary prevention of ASCVD (eg, transportation barriers, the availability of health services).Important considerations related to socioeconomic disadvantage are not captured by existing CVD risk equations.S2.1-31 Addressing unmet social needs improves management of BP and lipids,S2.1-32 which highlights the importance of dietary counseling and encouraging physical activity.S2.1-19 More time may be required to address ASCVD prevention with adults of low health literacy or disadvantaged educational backgrounds.Differential cardiovascular outcomes persist by important sociodemographic characteristics that include but are not limited to age, sex, and race/ethnicity.S2.1-22,S2.1-33–S2.1-35 Failure to address the impact of social determinants of health impedes efficacy of proven prevention recommendations. Table 2 outlines key considerations related to social determinants of health and ASCVD prevention.Table 2. Example Considerations for Addressing Social Determinants of Health to Help Prevent ASCVD EventsTopic/DomainExample ConsiderationsCardiovascular riskAdults should be routinely assessed for psychosocial stressors and provided with appropriate counseling.S2.1-31Health literacy should be assessed every 4 to 6 y to maximize recommendation effectiveness.S2.1-36DietIn addition to the prescription of diet modifications, body size perception, as well as social and cultural influences, should be assessed.S2.1-37,S2.1-38Potential barriers to adhering to a heart-healthy diet should be assessed, including food access and economic factors; these factors may be particularly relevant to persons from vulnerable populations, such as individuals residing in either inner-city or rural environments, those at socioeconomic disadvantage, and those of advanced age*.S2.1-39Exercise and physical activityIn addition to the prescription of exercise, neighborhood environment and access to facilities for physical activity should be assessed.S2.1- 30,S2.1-40,S2.1-41Obesity and weight lossLifestyle counseling for weight loss should include assessment of and interventional recommendations for psychosocial stressors, sleep hygiene, and other individualized barriers.S2.1-42–S2.1-44Weight maintenance should be promoted in patients with overweight/obesity who are unable to achieve recommended weight loss.Diabetes mellitusIn addition to the prescription of type 2 diabetes mellitus interventions, environmental and psychosocial factors, including depression, stress, self-efficacy, and social support, should be assessed to improve achievement of glycemic control and adherence to treatment.S2.1-45–S2.1-48High blood pressureShort sleep duration (<6 h) and poor-quality sleep are associated with high blood pressure and should be considered.S2.1-49 Because other lifestyle habits can impact blood pressure, access to a healthy, low-sodium diet and viable exercise options should also be considered.Tobacco treatmentSocial support is another potential determinant of tobacco use. Therefore, in adults who use tobacco, assistance and arrangement for individualized and group social support counseling are recommended.S2.1-50,S2.1-51*Advanced age generally refers to age ≥75 years.ASCVD indicates atherosclerotic cardiovascular disease.2.2. Assessment of Cardiovascular RiskSynopsisAssessment of ASCVD risk remains the foundation of primary prevention. Although all individuals should be encouraged to follow a heart-healthy lifestyle, estimating an individual’s 10-year absolute ASCVD risk enables matching the intensity of preventive interventions to the patient’s absolute risk, to maximize anticipated benefit and minimize potential harm from overtreatment. The 10-year ASCVD risk estimate is used to guide decision-making for many preventive interventions, including lipid managementS2.2-4,S2.2-36 and BP management;S2.2-37 it should be the start of a conversation with the patient about risk-reducing strategies (the “clinician–patient discussion”) and not the sole decision factor for the initiation of pharmacotherapy.S2.2-4,S2.2-36,S2.2-38 All risk estimation tools have inherent limitations, and population-based risk scores must be interpreted in light of specific circumstances for individual patients. The PCE have been shown to overestimateS2.2-15,S2.2-39–S2.2-47 or underestimateS2.2-12,S2.2-48–S2.2-51 ASCVD risk for certain subgroups. Thus, after calculation of the PCE, it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions for borderline- or intermediate-risk adults.S2.2-4–S2.2-14 However, the value of preventive therapy may remain uncertain for many individuals with borderline or intermediate estimated 10-year risk, and some patients may be reluctant to take medical therapy without clearer evidence of increased ASCVD risk. For these