New PREVENT Equation Lowers Risk Estimates, Raising Questions on Treatment Thresholds: AJPC Review, December 2025

The authors advocated the selective use of non-invasive imaging, specifically Coronary Artery Calcium (CAC) scores, in conjunction with risk prediction equations to help guide the primary prevention of ASCVD. Since the PREVENT equation tends to estimate a risk that is 30 to 50% lower than that of the pooled cohort’s equation, further guidance is needed to determine a suitable threshold for pharmacotherapy of hypertension and hyperlipidemia.

This succinct review is published in December 2025 in the American Journal of Preventive Cardiology.

CV Risk Assessment Calculators – How it Went from PCE to PREVENT?

Cardiovascular disease (CVD), an umbrella term including coronary artery disease (CAD), heart failure (HF), and stroke, often begins early and is driven largely by modifiable risk factors such as dyslipidemia and hypertension. Identifying high-risk individuals early is essential for timely pharmacotherapy to prevent major adverse cardiovascular events (MACE). The current U.S. standard, the 2019 ACC/AHA 10-year ASCVD risk calculator (Pooled Cohort Equation, PCE), has notable limitations: it does not reflect recent shifts in risk factors (e.g., reduced smoking but rising obesity and chronic kidney disease), overestimates ASCVD risk by about 41% overall, and lacks accuracy across diverse populations—underpredicting risk in South Asians and those with chronic inflammatory diseases, while overestimating it in East Asian and Hispanic groups. To address these gaps, the American Heart Association introduced the PREVENT risk equation in 2023.

PREVENT Equation – Robust Model Advancements

The PREVENT model marks a major advance in cardiovascular risk assessment. Developed and validated in >6 million adults aged 30–79 years—far larger and more diverse than the 48,733 participants used for the PCE—it is sex-specific and race-free, improving equity by removing race as a risk variable. PREVENT incorporates key factors such as HDL-C, non–HDL-C, systolic blood pressure, smoking status, BMI, use of lipid-lowering or antihypertensive medications, and eGFR, and importantly includes heart failure as a primary outcome. The model can also integrate Cardiovascular-Kidney-Metabolic (CKM) modifiers, including HbA1c, urine albumin–creatinine ratio, and the Social Deprivation Index (SDI), which reflects neighborhood-level socioeconomic risk.

Impact on Risk Stratification and Eligibility with PREVENT Equation

The PREVENT equation demonstrates superior calibration compared to its predecessor; the PCE has been found to overestimate risk by up to 50%. However, the use of PREVENT presents a clinical challenge regarding treatment eligibility. Studies comparing the two equations have consistently shown that the PREVENT model reclassifies a substantial portion of the population to a lower ASCVD risk category.

One study utilizing nationally representative data found that the PREVENT equation would reclassify 53% of adults into lower risk categories. If the current statin eligibility threshold of 7.5% 10-year risk were maintained unchanged, this reduction in calculated risk would translate to 14 million fewer people eligible for statins. Over a 10-year period, this profound decrease in treatment numbers could potentially result in an estimated 107,000 additional episodes of myocardial infarction or stroke. In view of this, further guidance is required to help determine a suitable threshold for pharmacotherapy.

Clinical Insights and Anticipated Future Horizon

The PREVENT model offers improved calibration and broader applicability, but its consistently lower 10-year ASCVD estimates highlight the need for clinical recalibration. Without updated treatment thresholds, relying on PREVENT may lead to undertreatment and increased cardiovascular events. Early steps toward adjustment are already reflected in the 2025 AHA/ACC Blood Pressure Guideline, which lowers the recommended 10-year CVD risk threshold for initiating therapy from 10% to 7.5% for select groups.

For clinicians, the evidence strongly supports pairing PREVENT with coronary artery calcium (CAC) scoring. In adults with borderline (5%–7.5%) or intermediate (7.5%–20%) risk, CAC remains the most effective tool to refine risk—particularly to “up-risk” patients who may benefit from starting or intensifying statin therapy. This phenotype-based approach is essential for personalized primary prevention.

Reference: Selvam PV, Sharma R, Ganz P, Blumenthal RS, Gulati M. Cardiovascular disease risk estimates using the new PREVENT Equation: The good, bad, and the ugly. Am J Prev Cardiol. 2025 Sep 11;24:101288. doi: 10.1016/j.ajpc.2025.101288. PMID: 41018255; PMCID: PMC12464685.