Why assess overall risk?
Blood pressure, cholesterol, smoking and age do not act independently. Overall cardiovascular risk estimates the likelihood of an event over a specified period, taking the combined effects of major risk factors into account. It supports a discussion about prevention; it does not predict with certainty what will happen to one person.
What SCORE2 and SCORE2-OP estimate
SCORE2 estimates the ten-year probability of fatal and non-fatal cardiovascular events in apparently healthy adults aged 40–69. SCORE2-OP is designed for older adults, aged 70–89, with interpretation adapted to later life. The models are calibrated for European regions with different underlying risks; Italy belongs to the moderate-risk region. The 2025 ESC/EAS focused update also endorses SCORE2 and SCORE2-OP for risk assessment in eligible adults.1,4
When a general risk chart is not enough
Standard SCORE2 charts should not be applied indiscriminately to people with established atherosclerotic cardiovascular disease, diabetes, clinically significant chronic kidney disease or familial hypercholesterolaemia. These conditions require dedicated assessment. SCORE2-Diabetes is intended for appropriate adults aged 40–69 with type 2 diabetes who do not already have atherosclerotic cardiovascular disease or severe target-organ damage; it should not simply be extended to older ages. The appropriate tool should be chosen by a healthcare professional.1,3
Risk estimates in an international context
The 2026 US cardiovascular-kidney-metabolic framework uses PREVENT equations to support primary prevention decisions, including assessment of atherosclerotic events and heart failure. This is a different framework from European SCORE2: population calibration, outcomes and treatment thresholds must be considered before comparing percentages. A score should never be selected merely because it gives the lowest result.2
Factors that can change the assessment
A family history of premature cardiovascular disease, raised lipoprotein(a), albuminuria and chronic inflammatory conditions may influence interpretation. In selected people, imaging for subclinical atherosclerosis, such as coronary artery calcium measurement, can help resolve uncertainty about prevention. Additional testing is not necessary for everyone.1
How to use the result
The estimate helps guide discussions about physical activity, nutrition, smoking cessation, blood pressure and lipid management, and medication when appropriate. Expected benefit should be considered alongside preferences, frailty, other illnesses and possible adverse effects. Decision thresholds are age-dependent and must be interpreted within the applicable guideline.
Understanding hypertension · Metabolic syndrome and the wider CKM framework
From risk assessment to prevention
Learn about blood pressure management and metabolic syndrome. For a discussion of how treatment benefits are communicated, see absolute and relative benefits of statins. The cardiac CT guide explains why calcium scoring and coronary angiography answer different questions.
About Massimo Fioranelli · Cardiology and internal medicine · Clinical practice at Sanatrix, Rome
References
- Visseren FLJ, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. European Heart Journal. 2021;42:3227–3337.
- AHA/ACC. Use of Predicted Risk and Expected Benefit to Guide Decision-Making in Cardiovascular-Kidney-Metabolic Syndrome. 2026.
- SCORE2-Diabetes Working Group and ESC Cardiovascular Risk Collaboration. SCORE2-Diabetes: 10-year cardiovascular risk estimation in type 2 diabetes in Europe. European Heart Journal. 2023;44:2544–2556. doi:10.1093/eurheartj/ehad260.
- Mach F, et al. 2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias. European Heart Journal. 2025;46:4359–4378.
English edition and scientific review: 23 October 2026. Educational information; individual assessment remains essential.