Table 1. Criteria for Classification of ASCVD

• Myocardial infarction or other acute coronary syndrome
• Coronary or other revascularization procedure
• Transient ischemic attack
• Ischemic stroke
• Atherosclerotic peripheral arterial disease
  • Includes ankle/brachial index <0.90
• Other documented atherosclerotic diseases such as:
  • Coronary atherosclerosis
  • Renal atherosclerosis
  • Carotid plaque, ≥50% stenosis
  • Aortic aneurysm secondary to atherosclerosis

Table 2. Major Risk Factors for ASCVD^a

^a Levels of non-HDL-C and LDL-C are not listed, because these risk factors are used to assess risk category and treatment goals for atherogenic lipoprotein cholesterol levels. (See Table 4) Diabetes mellitus is not listed because it is considered a high or very high risk condition for ASCVD risk assessment purposes.
^b CHD is defined as myocardial infarction (MI), coronary death, or a coronary revascularization procedure.

Table 3. Risk Calculators

^a These thresholds identify "high risk" individuals and are not intended to indicate "statin benefit" groups.

Table 4. Criteria for ASCVD Risk Assessment, Treatment Goals for Atherogenic Cholesterol, and Levels at Which to Consider Drug Therapy (mg/dL)

Table 5. High or Very High Risk Patient Groups

^a Patients in these categories are all at high or very high risk for an ASCVD event and should be treated accordingly.

Table 6. Sequential Steps in ASCVD Risk Assessment

^a Further risk assessment is not required after identifying the highest applicable risk level.
^b End organ damage indicated by increased albumin/creatinine ratio (≥30 mg/g), CKD, or retinopathy.
^c For patients with CKD stage 3B (GFR 30-44 mL/min/1.73 m²) or stage 4 (GFR 15-29 mL/min/1.73 m²) risk calculators should not be used because they may underestimate risk. Stage 5 CKD (or on hemodialysis) is a very high risk condition, but results from randomized, controlled trials of lipid-altering therapies have not provided convincing evidence of reduced numbers of ASCVD events in such patients. Therefore, no treatment goals for lipid therapy have been defined for stage 5 CKD.
^d High risk threshold is defined as ≥10% using ATP III Framingham Risk Score for hard CHD (MI or CHD death), ≥15% using the 2013 Pooled Cohort Equations for hard ASCVD (MI, stroke or death from CHD or stroke), or ≥45% using the Framingham long-term (to age 80) CVD (MI, CHD death or stroke) risk calculation. Clinicians may prefer to use other risk calculators but should be aware that quantitative risk calculators vary in the clinical outcomes predicted (eg, CHD events, ASCVD events, cardiovascular mortality), the risk factors included in their calculation, and the time frame for their prediction (eg, 5 years, 10 years, or long-term or lifetime). Such calculators may omit certain risk indicators that can be very important in individual patients, provide only an approximate risk estimate, and require clinical judgment for interpretation.

Table 7. Classifications of Cholesterol and Triglyceride Levels in mg/dL

^a Non-HDL-C = total-C minus HDL-C
^b Severe hypertriglyceridemia is another term used for very high triglycerides in pharmaceutical product labeling.

Table 8. Drugs That May Elevate LDL-C or Triglyceride Concentrations

Table 9. Risk Indicators (Other Than Major ASCVD Risk Factors) That Might be Considered for Risk Refinement^a

1. A severe disturbance in a major ASCVD risk factor, such as multi-pack per day smoking or strong family history of premature CHD
2. Indicators of subclinical disease, including coronary artery calcium ≥300 Agatston units^b is considered high risk
3. LDL-C ≥160 mg/dL and/or non-HDL-C ≥190 mg/dL
4. High-sensitivity C-reactive protein ≥2.0 mg/L^c
5. Lipoprotein (a) ≥50 mg/dL (protein) using an isoform insensitive assay
6. Urine albumin/creatinine ratio ≥30 mg/g

^a The presence of one or more of the risk indicators listed may be considered, in conjunction with major ASCVD risk factors, to reclassify an individual into a higher risk category. Except in the case of evidence of subclinical disease defining the presence of ASCVD, reclassification to a higher risk category is a matter of clinical judgment. Doing so will alter the threshold for consideration of pharmacotherapy and/or the treatment goals for atherogenic cholesterol. Many other ASCVD risk markers are available, but the NLA Expert Panel consensus view is that those listed have the greatest clinical utility.
^b Or coronary artery calcium ≥75th percentile for age, sex, and ethnicity. For additional information, see the CAC Score Reference Values web tool (http://www.mesa-nhlbi.org/CACReference.aspx.).
^c Because of high intra-individual variability, multiple high-sensitivity C-reactive protein (hs-CRP) values should be obtained before concluding that the level is elevated. hs-CRP should not be tested in those who are ill, have an infection, or are injured. If hs-CRP level is >10 mg/L, consider other etiologies such as infection, active arthritis, or concurrent illness.

Table 10. Diet Characteristics and Diseases/Disorders/Altered Metabolic States That May Elevate LDL-C and/or Triglyceride Concentrations

Table 11. Criteria for Clinical Identification of the Metabolic Syndrome (≥3 of the Listed Components)

^a American Heart Association/National Heart, Lung and Blood Institute guidelines for metabolic syndrome suggest waist circumference thresholds of ≥37 inches (≥94 cm) in men and ≥32 inches (≥80 cm) in women as optional cut points for individuals or populations with increased insulin resistance, including those of Asian descent (alternative values have also been published for other groups).
^b The most commonly used drugs for elevated triglyceride levels are fibric acids, nicotinic acid and high-dose long-chain omega-3 fatty acids. A patient taking any of these drugs may be presumed to have an elevated triglyceride level.
^c Most patients with type 2 diabetes mellitus will have the metabolic syndrome by these criteria.