Measure Components	The CDU uses a standard process/protocol for properly measuring/assessing ASCVD risk, including:
	1. Measurement of ASCVD Risk
	a. Use of ACC/AHA Risk Estimator139,140 is recommended. Others may be used as alternatives when evaluated in the population seen clinically.
	b. Healthcare providers identify the health provider responsible for insuring competency and implementation of risk assessment in practice.
	2. Incorporation Into Record
	a. Baseline risk should be part of patient demographics and included in each note when BP is 130–139/80–89 mm Hg, with indication of how it is used in defining treatment strategy.
	b. EMR for systems (eg, Epic, Cerner) should be requested to automatically place cardiovascular risk assessment in the patient record as part of vital signs.
	3. Confirmation of Patient-Clinician Discussion
	a. The risk assessment used in the patient-clinician discussion should be entered 1) directly by EHR (eg, Epic, Cerner) or 2) by physician or other healthcare provider as part of documentation of the discussion.
	b. Patients should be knowledgeable about their results and, if interested, may be instructed on how to use the mobile ASCVD risk assessment app.139,140
Rationale
Assessment of cardiovascular risk is the fundamental first step toward developing effective evidence-based therapy for treatment strategies for and shared decision discussions with patients. This includes using this assessment to correctly classify a patient’s current stage of HBP in accordance with recommendations from the 2017 Hypertension Clinical Practice Guidelines.4 In general, the ACC/AHA race- and sex-specific PCE (ASCVD Risk Estimator139,140) should be used for screening and management of hypertension. The 10-y risk is used for patients without ASCVD who have stage 1 hypertension (130/80–139/89 mm Hg) to determine those who should be treated with medical therapy (10-y risk >10%) and those who should who should be managed with nonpharmacological therapy (10-y risk <10%). Patients should know their current cardiovascular risk and how it relates to decisions about their therapy.
Observational studies have demonstrated that ASCVD risk factors frequently occur in combination, with ≥3 risk factors present in 17% of patients.141 A meta-analysis from 18 cohort studies involving 257 384 patients identified a lifetime risk of ASCVD death, nonfatal MI, and fatal or nonfatal stroke that was substantially higher in adults with ≥2 ASCVD risk factors than in those with only 1 risk factor.141,142
To facilitate decisions about preventive interventions, it is recommended to screen for traditional ASCVD risk factors and apply the race- and sex-specific PCE (ASCVD Risk Estimator139,140) to estimate 10-y ASCVD risk for asymptomatic adults 40–75 y of age.59,139,140 For management of blood cholesterol, adults should be categorized as having low (<5%), borderline (5% to <7.5%), intermediate (≥7.5% to <20%), or high (≥20%) 10-y risk.143 The PCEs are best validated among non-Hispanic whites and non-Hispanic blacks living in the United States.19,144–147 In other racial/ethnic groups148,149 or in some non-US populations,148–151 the PCE may over- or under-estimate risk. Therefore, clinicians may consider use of another risk prediction tool, as an alternative to the PCE, if validated in a population with similar characteristics to the evaluated patient. Examples include the general Framingham ASCVD risk score,152 Reynolds risk scores,153,154 SCORE,155 and QRISK/JBS3156 tools. Other professional societies have incorporated some of these alternative validated risk scores into their lipid management guidelines or have considered different risk thresholds for preventive interventions.155–160 Although slight differences exist across organizational guidelines, they are all very similar in their overarching goal of matching the intensity of preventive therapies to absolute (generally 10-y) risk of the patient.155–160
Clinical Recommendations
2017 Hypertension Clinical Practice Guidelines4
Recommendation for Screening and Management of CVD Risk (Guideline Section 2.4)
1. Screening for and management of other modifiable CVD risk factors are recommended in adults with hypertension.141,142 (Class 1, Level of Evidence: B-NR)
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease14
Recommendation for ASCVD Risk Assessment (Section 2.2, 2019 Prevention Guideline)
1. For adults 40 to 75 y of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate 10-y risk of ASCVD by using the pooled cohort equations (PCE).139,140,146 (Class 1, Level of Evidence: B-NR)

ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CDU, care delivery unit; CVD, cardiovascular disease; DBP, diastolic blood pressure; EHR, electronic health record; HBP, high blood pressure; MI, myocardial infarction; PCE, pooled cohort equations; QCDR, Qualified Clinical Data Registry; and SBP, systolic blood pressure.