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). 
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).  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.
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. 
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). 
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.