How do the 2025 ACC/AHA guidelines define 10-year ASCVD risk categories and which calculator should clinicians use?

1. What the guidelines now count as “10‑year risk” and the new threshold language

The updated guidance expands the practical target of 10‑year risk assessment beyond only atherosclerotic cardiovascular disease events to encompass a broader set of outcomes (including heart failure) when informing blood‑pressure treatment thresholds, and endorses a 7.5% 10‑year risk cutpoint as the decision threshold used in the guideline recommendations for initiating or intensifying preventive therapy—language reinforced in the scientific statement accompanying the guideline ^{[1] [2]}.

2. Which equation the guideline recommends clinicians use for BP‑guided prevention: PREVENT

For the 2025 blood‑pressure guideline, the ACC/AHA favors implementation of the PREVENT risk equation — a newer model that incorporates cardiovascular, kidney, and metabolic risk factors, can be applied beginning at age 30, and predicts both 10‑ and 30‑year risks of myocardial infarction, stroke, and heart failure — and is presented as supplanting the PCE for BP‑guided primary prevention decisions ^{[1] [2]}.

3. The continuing role of the Pooled Cohort Equations and ACC/AHA tools

Despite PREVENT’s adoption for BP strategy, longstanding guidance still frames the Pooled Cohort Equations as a valid, widely used estimator of 10‑year risk for a first hard ASCVD event (nonfatal MI, CHD death, fatal or nonfatal stroke); ACC/AHA tools and the ASCVD Risk Estimator Plus app continue to provide PCE‑based 10‑year ASCVD estimates and lifetime risk functions, and remain useful for clinician‑patient discussions and shared decision‑making ^{[4] [5] [6] [7]}.

4. Practical recommendation for clinicians navigating the transition

Clinicians treating patients under the 2025 BP guideline should use PREVENT when the guideline’s blood‑pressure management algorithm is being applied, while using PCE‑based tools (such as the ACC/AHA ASCVD Risk Estimator Plus or validated online calculators) when the clinical question specifically concerns 10‑year risk of an atherosclerotic event and when counseling about interventions tied to ASCVD outcomes; the guideline and companion statements frame PREVENT as the preferred model for BP decisions but treat the PCE as an important, familiar starting point for ASCVD‑specific shared decision‑making ^{[1] [3] [5]}.

5. Caveats, validation gaps, and fairness concerns

Both approaches have limitations that clinicians must weigh: the PCE were developed and validated primarily in non‑Hispanic White and Black populations and have known calibration issues in other racial and ethnic groups, and guideline authors note ongoing validation work and the need for broader external testing of PREVENT across populations and settings before it is assumed universally superior ^{[8] [9] [2]}. In short, PREVENT is promoted in the 2025 BP guideline for its broader risk construct and younger age applicability (30+), but clinicians should remain attentive to ongoing validation studies and to communicating uncertainty when applying either model in understudied populations ^{[1] [9] [8]}.

6. Where this leaves patient conversations and decision tools

The ACC/AHA continues to recommend quantitative risk estimation as the start of a shared decision process; whether using PREVENT for BP decisions or PCE for ASCVD‑specific counseling, clinicians are urged to translate model outputs into individualized discussions about lifestyle, pharmacotherapy, and projected risk reduction — a role that ACC tools and visualizers are designed to support even as the preferred analytic engine shifts toward PREVENT for certain guideline decisions ^{[6] [7] [5]}.