Definition and Scope of Atherosclerotic Cardiovascular Disease (ASCVD)

Overall Definition

ASCVD includes any clinical condition caused by atherosclerosis such as acute coronary syndromes, myocardial infarction, stable or unstable angina, angiographically documented coronary artery disease, any coronary or arterial revascularization, ischemic stroke or transient ischemic attack, documented carotid disease, peripheral artery disease, and abdominal aortic aneurysm. [1][2]3

Acute coronary syndrome (unstable angina or myocardial infarction) is classified as ASCVD. [1][2]3
A prior myocardial infarction, whether recent or remote, qualifies as ASCVD. [2][3]
Stable angina, defined as chronic coronary syndrome with documented ischemia, is included in ASCVD. [1][4]
Unstable angina without biomarker elevation is considered ASCVD. [2][3]
Coronary artery disease identified on angiography counts as ASCVD regardless of symptom status. [1][4]

Any previous coronary artery bypass graft surgery is an ASCVD event. [1][4]
Percutaneous coronary intervention (including stenting or angioplasty) is an ASCVD event. 3
Femoral‑popliteal bypass surgery for lower‑extremity arterial reconstruction is included in ASCVD. 1
Other arterial revascularizations (e.g., carotid endarterectomy, renal artery stenting) are ASCVD events. [2][4]

Documented ischemic stroke of atherosclerotic origin is part of ASCVD. [1][2]3
Transient ischemic attack caused by vascular insufficiency is classified as ASCVD. [2][3]
Significant carotid artery stenosis, even when asymptomatic, is considered ASCVD. [1][4]

Peripheral artery disease, including symptomatic claudication or documented arterial insufficiency, is ASCVD. [2][3]
Abdominal aortic aneurysm of atherosclerotic origin is included in ASCVD. [1][2]3

Only conditions that are atherosclerotic in origin meet the ASCVD definition; heart failure, atrial fibrillation, valvular disease, and non‑ischemic cardiomyopathy are excluded unless they result from ischemic heart disease. [2][3][5][6]7

All ASCVD patients are automatically eligible for statin therapy, but additional high‑risk primary‑prevention groups (diabetes mellitus, chronic kidney disease, LDL‑C ≥5.0 mmol/L, familial hypercholesterolemia) are statin‑indicated without being classified as ASCVD until an atherosclerotic event occurs. [1][4][8][9]

Presence of any ASCVD manifestation places the patient in the secondary‑prevention category, mandating the most intensive risk‑factor modification irrespective of baseline lipid levels. [1][4]
ASCVD status supersedes formal risk‑calculator scores and requires aggressive lipid‑lowering therapy. [2][3]6

Patients with multiple major ASCVD events (e.g., myocardial infarction plus stroke) are designated very high‑risk. 3
A single major ASCVD event combined with multiple high‑risk conditions (e.g., diabetes, chronic kidney disease, heart failure, age ≥ 65 years, hypertension, current smoking, or persistently elevated LDL‑C despite maximal therapy) qualifies as very high‑risk. 3
Recent acute coronary syndrome within the past 12 months also confers very high‑risk status. 3

Subclinical atherosclerosis (coronary artery calcium scoring, carotid intima‑media thickness, asymptomatic plaques) should not be mistaken for clinical ASCVD; these are risk enhancers for primary prevention, not indications for secondary‑prevention therapy. [7][10]
Not all cardiovascular conditions are ASCVD; clinicians must verify the atherosclerotic origin before assigning ASCVD status, especially for heart failure, arrhythmias, and valvular disease. [9][5]6