In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.
ACVC Clinical Decision-Making Toolkit

One of the best tools to help practitioners make the best bedside clinical decisions when managing patients with acute cardiovascular disease.

See more

Individual risk assessment in secondary prevention for cardiovascular disease

The role of individual risk assessment in secondary prevention for cardiovascular disease

Better individualised estimates of risk in patients with previous cardiovascular disease will enable more  intensive treatment, motivation and follow-up in identified high-risk individuals.

Updated by Jannick A.N. Dorresteijn, 3 September 2021

European guidelines on cardiovascular disease (CVD) prevention in clinical practice state that patients with documented CVD are at very high-risk of recurrent cardiovascular events and mortality before initiation of general prevention goals, but varying degree of residual risk thereafter. [1, 2, 3] Estimates of residual risk after achievement of general prevention goals (step 1) may be used to guide decisions about intensified preventive treatment options (step 2). [1]

The SMART risk score estimates individual risk for myocardial infarction, stroke or vascular death in the next 10 years if standard care is provided. The SMART risk score can be used for all individual patients with clinical manifest atherosclerotic vascular disease (ASCVD). [2] These include coronary artery disease, cerebrovascular disease, peripheral artery disease, abdominal aortic aneurysm and polyvascular disease. It is based on common, easy-to-measure, clinical patient characteristics.

Access the SMART Risk score

High-risk individuals are more likely to benefit from preventive treatment, such as cholesterol-lowering, blood pressure-lowering or novel drugs. High-risk patients experience a larger absolute risk reduction (ARR) and subsequently have a lower number needed to treat (NNT) from any type of preventive treatment. [4]

Intensified preventive treatment options (step 2) that one might reserve for patients with high residual risk are: systolic blood pressure target <130 mmHg, LDL-cholesterol target <1.4 mmol/L, dual antiplatelet therapy, dual pathway inhibition antithrombotic therapy, and novel upcoming interventions (e.g. colchicine, EPA). [1]

In addition, individual 10-year risk estimations for (recurrent) major cardiovascular events can also be used for patient education. This may provide the patient with more insight in their personal prognosis and, thereby, increase their motivation and positively impact adherence to preventive interventions. 


[1] Frank L J Visseren, François Mach, Yvo M Smulders et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice, European Heart Journal, ehab484,
30 August 2021

[2] Dorresteijn JA, Visseren FL, Wassink AM ea. Development and validation of a prediction rule for recurrent vascular events based on a cohort study of patients with arterial disease: the SMART risk score.

Heart. 2013 Jun;99(12):866-72.

[3] Kaasenbrood L, Boekholdt SM, van der Graaf Y ea. Distribution of Estimated 10-Year Risk of Recurrent Vascular Events and Residual Risk in a Secondary Prevention Population. Circulation. 2016 Nov 8;134(19):1419-1429.

[4] Dorresteijn JA, Visseren FL, Ridker PM ea. Estimating treatment effects for individual patients based on the results of randomised clinical trials. BMJ. 2011 Oct 3;343:d5888.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer for good, and Sanofi and Regeneron in the form of educational grants.