Long-term risk assessment in primary prevention: making the case for 30-year PREVENT scores

This editorial refers to ‘Relationship between 10- and 30-year PREVENT risk scores with coronary artery calcium and incident atherosclerotic cardiovascular disease: MESA’, by R. Rikhi et al., https://doi.org/10.1093/eurjpc/zwaf770. The PREVENT (Predicting Risk of cardiovascular disease EVENTs) equations improved upon existing risk discrimination methods, such as the pooled cohort equation (PCE).1,2 Now we ask: What is the next step? In this issue, Rikhi et al.3 provide compelling evidence that expanding our temporal horizon from the current 10-year framework to a comprehensive 30-year perspective may identify a substantial cohort of individuals who, despite low short-term risk, harbour significant lifetime cardiovascular disease (CVD) burden. This represents a paradigm shift in risk assessment, especially for younger patients, and perhaps the next step for further improvement in atherosclerotic CVD (ASCVD) prevention. Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), the authors examined 6747 adults aged 45–84 years who were free of clinical CVD at baseline. Their central finding challenges conventional risk stratification: nearly one-third of participants classified with a low 10-year ASCVD risk ( 0 at baseline by cross-tabulation of 10-year and 30-year PREVENT atherosclerotic cardiovascular disease risk categories (Group 1 = concordant low risk, 15.6% coronary artery calcium prevalence; Group 2 = discordant risk, 36.2% coronary artery calcium prevalence). (B) Hazard ratios for incident atherosclerotic cardiovascular disease events, adjusted for age, sex, race/ethnicity, and baseline coronary artery calcium score. ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CI, confidence interval. The authors employed a novel approach to risk stratification by calculating both 10-year PREVENT and 30-year risk scores for each participant and cross-tabulating individuals into concordant and discordant risk categories. The 10-year ASCVD risk thresholds followed established clinical guidelines4: low risk (