Cardiovascular disease (CVD) risk prediction has been the cornerstone of prevention practice for decades because it identifies the individuals most likely to benefit from therapeutic intervention. While the relative risk reduction observed with lipid-lowering therapy is similar for patients with low and high absolute risk, the clinical impact of lipid-lowering therapy depends on the baseline absolute risk and consequently, the absolute risk reduction. It is for this reason that both US1 and European2 prevention guidelines emphasise global CVD risk estimation as a guide to treatment decisions.

While there is broad agreement on the importance of absolute risk, the clinical application of these risk estimates has been the subject of considerable debate. In the past, statin therapy was more expensive and therefore guidelines recommended treatment for only those at the higher end of the risk distribution. However, with generic statins and decades of safety data, guidelines have lowered risk thresholds with many more patients now candidates for therapy, giving rise to new concerns about treating too many, rather than too few patients.

Despite these changing trends in short-term risk treatment thresholds, other more fundamental challenges persist—namely, age remains the dominant determinant of short-term absolute risk …