Revised Pooled Cohort Equations (2018)
This tool estimates the 10-year risk for atherosclerotic
(ASCVD) which is defined as coronary death or nonfatal myocardial infarction, or
or nonfatal stroke. Yadlowsky S, Hayward RA, et al. stated
that the previous 2013 pooled cohort equations overestimated the 10-year risk
for atherosclerotic CVD by an average of 20% across risk groups.
Systolic Blood Pressure
Yes Treatment for Hypertension :
Yes Smoker :
Estimates of 10-year risk for atherosclerotic cardiovascular disease (ASCVD) are
valid for ages 40 through 79.
Key facts: 1
In order to estimate the risk for atherosclerotic
cardiovascular disease, the following information is
Systolic blood pressure,
Blood pressure lowering medication use,
Diabetes status, and
"Ten-year risk is defined as the risk of developing a first
ASCVD event, defined as nonfatal myocardial infarction or
coronary heart disease (CHD) death, or fatal or nonfatal stroke, over a 10-year
period among people free from ASCVD at the beginning of the
The 2013 ACC/AHA Guideline focuses on the following:
The large proportion of the adult population
WITHOUT clinical signs or symptoms of ASCVD that
require evaluation for the primary prevention of
atherosclerotic cardiovascular disease (ASCVD).
The guidelines do not apply to individuals with
clear clinical signs and symptoms of atherosclerotic
cardiovascular disease (ASCVD) who require
alternative approaches or diagnostic strategies
rather than an assessment of risk.
"The recommendations were not developed for use in specific
subgroups of asymptomatic individuals at unusually high
risk, such as those with genetically determined extreme
values of traditional risk factors."
The Pooled Cohort Equations were derived and
validated by the ACC/AHA Work Group by using state-of-the-art statistical
Only variables that were found to be statistically
significant were included in the equations such as age,
total and HDL-cholesterol, systolic BP (including
treated or untreated status), diabetes, and current
Several other factors and potential risk factors
were reviewed for possible inclusion, however, many of
these factors did not provide the necessary additional
guidance needed for inclusion. In some cases the
data was insufficient during the validation studies and
may be revisited in the future.
The final Pooled Cohort Equations have been
"subjected to more rigorous validation than other currently available
equations, and they are the only risk assessment equations that include significant numbers of African
Americans and focus on estimation of 10-year risk."
Other ethnic groups: The pooled cohort equations were created for either
non-Hispanic white men or women ages 40 through 79
years. The results may be OVER or UNDER estimated for
other groups. Groups likely to be underestimated include
American Indians some Asian Americans and some Hispanics
e.g. Puerto Ricans. Overestimates may occur in some
Asian Americans - east Asian ancestry and some Hispanics
- e.g. Mexican Americans.
Future goals: The ACC/AHA Work Group will
continue to expand on the current research and will
hopefully develop new equations for other ethnic groups
and provide further validation and enhancements to the
currently released pooled cohort equations.
In many cases direct quotes are used from the primary reference:
Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum
CB, McBride P, Eckel RH, Schwartz JS, Goldberg AC, Shero ST, Gordon D, Smith SC
Jr, Levy D, Watson K, Wilson PW. 2013 ACC/AHA Guideline on the Treatment of
Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A
Report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii:
S0735-1097(13)06028-2. doi: 10.1016/j.jacc.2013.11.002.
Four 'Statin Benefit Groups' have been identified that have the potential to
reduce the risk of atherosclerotic cardiovascular disease. The benefit of
therapy has been found to clearly exceed the potential for adverse effects in
adults. The four groups are as follows:
Individuals with clinical ASCVD (Secondary prevention): Clinical ASCVD
Atherosclerotic Cardiovascular Disease is defined
by the inclusion criteria for the secondary prevention statin RCTs (acute
coronary syndromes, or a history of MI, stable or unstable angina, coronary
or other arterial revascularization, stroke, TIA, or peripheral arterial
disease presumed to be of atherosclerotic origin).
Individuals with primary elevations of LDL-C
Individuals 40 to 75 years of age with diabetes and LDL-C 70-189 mg/dL.
For the primary prevention of ASCVD in individuals with diabetes (diabetes
mellitus type-1 and type-2), estimated 10-year ASCVD risk can also be used
to guide the intensity of statin therapy.
Individuals without clinical ASCVD or diabetes who are 40 to 75 years of
age with LDL-C 70- 189 mg/dL and an estimated 10-year ASCVD risk of 7.5% or
higher. Data has shown that statins used for primary prevention
have substantial ASCVD risk reduction benefits across the range of LDL-C
levels of 70-189 mg/dL.
Initial steps: Counseling on a
heart healthy lifestyle forms the foundation of ASCVD prevention.
Pooled Cohort equations: Individuals not receiving cholesterol-lowering drug therapy,
should have their
estimated 10-year ASCVD risk calculated initially, and then every 4 to 6 years in individuals aged 40 to 75 years
without clinical Atherosclerotic Cardiovascular Disease or diabetes and with LDL-C 70-189 mg/dL. Decision point:
1] Adults age >21 years old and a candidate for statin therapy [if Yes] AND
[if YES] --> 2 paths:
(a) Age 75 years -
[if YES] Start High-intensity statin (Use Moderate-intensity statin
if not a candidate for high-intensity
Background: (direct quotes) 3 Moderate-intensity statin therapy should be used in individuals in
whom high-intensity statin therapy would otherwise be recommended when
characteristics predisposing them to statin associated
adverse effects are present. Characteristics predisposing individuals to statin
adverse effects include, but are not limited to:
Multiple or serious
comorbidities, including impaired renal or hepatic function.
History of previous statin intolerance or muscle disorders.
Unexplained ALT elevations >3 times ULN.
Patient characteristics or
concomitant use of drugs affecting statin metabolism.
>75 years of age.
Age >75y or if not candidate for high-intensity statin-->[if
moderate-intensity statin. Decision point: 2] LDL-C
YES] --> Start high-intensity statin (Moderate-intensity statin
if not a candidate for high-intensity statin). Decision point: 3] Diabetes type 1 or 2 AND age 40-75y
AND LDL-C 70-189 mg/dL.? [ if YES] --> Start Moderate-intensity statin
[ support for high-intensity: "Giving a maximally tolerated statin intensity
should receive primary emphasis because it most accurately reflects the data
that statins reduce the relative risk of ASCVD events similarly in individuals
with and without diabetes, and
in primary and secondary prevention in those with diabetes, along with evidence
statins reduce ASCVD events more than moderate-intensity statins."] Decision point: 4] No to all above? -->[if
YES] Estimate the 10-year ASCVD risk with
the Pooled Cohort
Is the estimated 10-y risk 7.5
AND age 40-75 [if YES] --> Start Moderate
to high intensity statin.
IF e.g. estimated 10-y risk <7.5 --> ASCVD
prevention benefit of statin therapy may be less clear in other groups. In
selected individuals, consider the following: NO
Review additional factors influencing ASCVD risk
Review potential ASCVD treatment risks, benefits and adverse effects
Review potential drug-drug interactions
patient preferences for statin treatment.
Statin therapy: monitoring therapeutic response and adherence: Flowchart:
Assess medication and lifestyle adherence - fasting lipid panel etc.
Was the anticipated response achieved ? [E.g.
high-intensity statin regimen:
50 percent reduction
in LDL-C from untreated baseline or moderate-intensity statin therapy- LDL-C
reduction of ~30 - <50% from untreated baseline]
YES] --> - reinforce
continued adherence --> follow-up in 3 to 12 months. [if
NO] --> (Less than
anticipated result) --> [Was there intolerance to the recommended statin
dose - [YES / NO] -->
YES] - Review the
section on management of statin intolerance (Stone NJ et al.
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to
Reduce Atherosclerotic Cardiovascular Risk in Adults: ....) [if
NO] - reinforce
medication adherence and adherence to intensive lifestyle changes.
Also exclude secondary causes of hypercholesterolemia.
Follow-up in 4 to 12 weeks.
Goff DC Jr, Lloyd-Jones DM, Bennett G, O'Donnell CJ, Coady S,
Robinson J, D'Agostino RB Sr, Schwartz JS, Gibbons R, Shero ST,
Greenland P, Smith SC Jr, Lackland DT, Sorlie P, Levy D, Stone NJ,
Wilson PW. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular
Risk: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013
Nov 12. pii: S0735-1097(13)06031-2. doi: 10.1016/j.jacc.2013.11.005.
Lloyd-Jones DM, Leip EP, Larson MG, D'Agostino RB, Beiser A, Wilson
PW, Wolf PA, Levy D. Prediction of lifetime risk for
cardiovascular disease by risk factor burden at 50 years of age.
Circulation. 2006 Feb 14;113(6):791-8. Epub 2006 Feb 6.
Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones
DM, Blum CB, McBride P, Eckel RH, Schwartz JS, Goldberg AC, Shero ST,
Gordon D, Smith SC Jr, Levy D, Watson K, Wilson PW. 2013 ACC/AHA
Guideline on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice
Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06028-2.
Yadlowsky S, Hayward RA, Sussman JB, McClelland RL, Min YI, Basu S.
Clinical Implications of Revised Pooled Cohort Equations for Estimating
Atherosclerotic Cardiovascular Disease Risk. Ann Intern Med. 2018 Jul
3;169(1):20-29. doi: 10.7326/M17-3011. Epub 2018 Jun 5. [
Background: The 2013 pooled cohort equations
(PCEs) are central in prevention guidelines for cardiovascular
disease (CVD) but can misestimate CVD risk.
Objective: To improve the clinical
accuracy of CVD risk prediction by revising the 2013 PCEs using
newer data and statistical methods. Design: Derivation
and validation of risk equations. Setting:
Population-based. Participants: 26689
adults aged 40 to 79 years without prior CVD from 6 U.S.
cohorts. Measurements: Nonfatal
myocardial infarction, death from coronary heart disease, or
fatal or nonfatal stroke. Results:
The 2013 PCEs overestimated 10-year risk for atherosclerotic CVD
by an average of 20% across risk groups. Misestimation of risk
was particularly prominent among black adults, of whom 3.9
million (33% of eligible black persons) had extreme risk
estimates (<70% or >250% those of white adults with
otherwise-identical risk factor values). Updating these
equations improved accuracy among all race and sex subgroups.
Approximately 11.8 million U.S. adults previously labeled
high-risk (10-year risk >/=7.5%) by the 2013 PCEs would be
relabeled lower-risk by the updated equations. Limitations: Updating the 2013 PCEs with
data from modern cohorts reduced the number of persons
considered to be at high risk. Clinicians and patients should
consider the potential benefits and harms of reducing the number
of persons recommended aspirin, blood pressure, or statin
therapy. Our findings also indicate that risk equations will
generally become outdated over time and require routine
updating. Conclusion: Revised PCEs
can improve the accuracy of CVD risk estimates. Primary Funding
Source: National Institutes of Health.