PREVENT Risk Calculator for Cardiovascular Disease
Lilian White, MD
Posted on March 3, 2025
The Framingham risk score was the first risk calculator developed to help inform primary prevention for cardiovascular disease (CVD) in 1998. The calculator used data from the Framingham Heart Study, one of the first longitudinal studies evaluating CVD.
The Pooled Cohort Equations (PCEs) risk calculator was developed by the American College of Cardiology/American Heart Association in 2013 and largely replaced the Framingham risk calculator. The PCEs added data concerning fatal and nonfatal stroke, making it more comprehensive compared with the Framingham score. Limitations of the PCEs include lack of consideration of social determinants of health, chronic renal disease, tendency to overestimate risk, and use of race as a factor.
The Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) app was developed in 2023 from a large observational cohort study of more than 6 million adults. The study was conducted from 1992-2017, making it more applicable to the current population compared with previous calculators, which relied on older studies. Additionally, the PREVENT app includes the use of estimated glomerular filtration rate, urine albumin-creatinine ratio, zip code (as a surrogate factor for socioeconomic factors), and A1C in addition to most of the factors previously considered in the PCEs. The PREVENT app also includes an option for assessing the risk of developing heart failure separately from cardiovascular disease (which includes myocardial infarction and heart failure) as well as 10- and 30-year risk estimates.
Notably, the PREVENT app does not include low-density lipoprotein (LDL), diastolic blood pressure, or race, which were a part of the PCEs. It is interesting that LDL—long referred to as the “bad cholesterol”—is not included. No specific comment in the PREVENT study addresses this, although more recent evidence has demonstrated LDL is not as predictive of CVD as non-high density lipoprotein, which the PREVENT app uses.
PCEs tends to overestimate risk such that 40% to 50% of middle-aged Americans would qualify for statin therapy (ie, a PCEs score greater than 7.5%, which is the recommended threshold to consider treatment). The PREVENT app considers noncardiovascular causes of death to help reduce the risk of overestimation of risk and treatment benefit.
New guidelines for primary prevention of cardiovascular, atherosclerotic, and heart failure incorporating the use of the PREVENT app are likely forthcoming. Specific recommendations to consider de-prescribing statin and other medications based on the PREVENT app for a patient are likely coming in the future as well. Future risk calculators may consider inclusion of additional risk factors for CVD such as apolipoprotein B, C-reactive protein, and social or community connectedness, in addition to the new foundation laid by the PREVENT model.
Additional information on the new PREVENT app can be found in an American Family Physician Point-of-Care Guide and in its related editorial.