Recalculating Risk: Introducing the PREVENT Risk Equations

Cardiovascular risk calculators have been incorporated into treatment considerations, guidelines, and patient education for almost 30 years. The first widely used risk calculator originated with the famous Framingham Heart Study in Framingham, Massachusetts. The Framingham Risk calculator was published in 1998 and predicted the 10-year risk estimate of coronary heart disease. It included sex-specific equations based on factors such as age, smoking status, blood pressure, and cholesterol. These equations were based on a cohort of about 5,000 middle-aged white people in a single geographical area from 1971-1974.¹ The population inclusion alone points to major complications with the generalizability of these equations as they went into practice.

To address these shortcomings, the American Heart Association (AHA) published the Pooled Cohort Equations (PCEs) in 2013, which are sex- and race-specific.² The PCEs used a large population size of around 25,000 patients from 5 different community cohorts, increasing the racial diversity of the equation population. In addition, the PCEs expanded results for atherosclerotic cardiovascular disease (ASCVD) outcomes, including stroke. The risk estimates were incorporated into many guidelines, such as the 2013, 2018, and 2019 ACC/AHA guidelines on cardiovascular disease primary prevention and cholesterol management. However, the PCEs’ results have since been criticized due to findings of both over- and underestimation of risk in select populations.^3,4

Is There a Better Way to Screen for Cardiovascular Risk?

In 2023, AHA published the Predicting Risk of Cardiovascular Disease Events (PREVENT™) equations. These updated risk equations were meant to address three key areas: “(1) The need for risk equations based on contemporary, diverse datasets that include individuals who are representative of the patient population intended for use, (2) incorporation of predictors and outcomes relevant to the growing burden of chronic kidney disease and heart failure, and (3) expansion to include younger adults starting at 30 years of age with a longer time horizon for estimated risk.”⁵ To achieve this, the equations were derived from a large dataset comprising over 6.6 million adults from 46 study cohorts and EMR data.⁶Additionally, they include new inputs of BMI and eGFR in addition to historically used inputs such as age, cholesterol, blood pressure, etc. This expansion and changes reflect AHA’s shift to focus on cardiovascular, kidney, and metabolism diseases as a whole, referred to as CKM.

The PREVENT™ equations also include additional optional inputs of urine albumin-to-creatinine ratio, hemoglobin A1c, and ZIP code.⁷ ZIP code is utilized in the PREVENT™ equations to address social determinants of health using the Social Deprivation Index (SDI) as a factor. SDI is a validated tool from the Robert Graham Center that quantifies an area's socioeconomic characteristics. This addition was found to provide a more accurate risk prediction across racial groups than race identity solely in the development of the equations, which is why the PREVENT™ equations do not include race as an input.⁷ The results of the PREVENT™ equations are also different as they include a composite cardiovascular disease risk along with individual ASCVD and HF risks for both a 10- and 30-year time frame.⁶

Validation of risk models is often expressed using a calibration slope, which represents the observed events vs. the model’s predicted events. Therefore, the value of 1 represents perfect calibration. The PREVENT™ equations were found to have a strong calibration slope ranging from 0.94 to 1.09 across equations, compared with the PCEs calibration slope of 0.54 to 0.5 (7).This correlates with a 2024 study of over 3,700 patients that directly compared PREVENT™ to the PCEs risk estimation. Interestingly, this study found a mean ASCVD risk estimate of 4.3% vs 8% in the study population, respectively.⁸ The lower estimation of risk from the PREVENT™ calculator was consistent across all subgroups of age, sex, and race.

Using PREVENT^TM in Practice

Since its recent publication in 2023, PREVENT™ has not been incorporated into any major guidelines until this year. The 2025 ACC/AHA et al. The High Blood Pressure Guideline incorporated the PREVENT™ calculator into its decision tree recommendations, replacing the PCEs.⁹ In stage 1 hypertension, patients without CVD or other comorbidities are recommended to initiate antihypertensive treatment if they have a PREVENT™ composite score ≥ 7.5%.⁹ Additionally, the 2025 ADA Standards of Diabetes Care recommend assessment of ASCVD risk but removed a specific calculator in this recommendation.¹⁰ With future guideline updates, PREVENT™ may continue to replace the PCEs as the recommended risk calculation. However, for now, the PREVENT™ results can better inform discussions with patients about their risk of cardiovascular disease events.

REFERENCES

1. Wilson PWF, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of Coronary Heart Disease Using Risk Factor Categories. Circulation. 1998 May 12;97(18):1837–47.

2. Goff DC, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation [Internet]. 2014 June 24 [cited 2025 Sept 27];129(25_suppl_2). Available from: https://www.ahajournals.org/doi/10.1161/01.cir.0000437741.48606.98

3. Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC, Sperling LS, Virani SS, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology. Circulation [Internet]. 2019 June 18 [cited 2025 Oct 6];139(25). Available from: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000638

4. Lloyd-Jones DM. The Pooled Cohort Equations and the Test of Time. Journal of the American College of Cardiology. 2023 Oct;82(15):1509–11.

5. Khan SS, Lloyd-Jones DM, Abdalla M, Bello NA, Blyler CA, Carter J, et al. Use of Risk Assessment to Guide Decision-Making for Blood Pressure Management in the Primary Prevention of Cardiovascular Disease: A Scientific Statement From the American Heart Association and American College of Cardiology. JACC. 2025 Aug;S0735109725073425.

6. Khan SS, Coresh J, Pencina MJ, Ndumele CE, Rangaswami J, Chow SL, et al. Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association. Circulation. 2023 Dec 12;148(24):1982–2004.

7. Khan SS, Matsushita K, Sang Y, Ballew SH, Grams ME, Surapaneni A, et al. Development and Validation of the American Heart Association’s PREVENT Equations. Circulation. 2024 Feb 6;149(6):430–49.

8. Anderson TS, Wilson LM, Sussman JB. Atherosclerotic Cardiovascular Disease Risk Estimates Using the Predicting Risk of Cardiovascular Disease Events Equations. JAMA Intern Med. 2024 Aug 1;184(8):963.

9. Writing Committee Members*, Jones DW, Ferdinand KC, Taler SJ, Johnson HM, Shimbo D, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension [Internet]. 2025 Oct [cited 2025 Oct 6];82(10). Available from: https://www.ahajournals.org/doi/10.1161/HYP.0000000000000249

10. American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Bajaj M, Balapattabi K, et al. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S59–85.