Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, underscoring the importance of effective primary prevention strategies. Current total cardiovascular disease (CVD) risk assessment tools, such as the Systematic Coronary Risk Evaluation 2 (SCORE2) in Europe and the Pooled cohort equations (PCEs) and Predicting Risk of CVD EVENTs (PREVENT) in the USA, aim to identify individuals at high CVD risk and guide clinical decision-making in the primary prevention setting. Statin therapy reduces cardiovascular events and is recommended as the first step for individuals with estimated CVD risk above specific thresholds. Moreover, the presence of risk modifiers, as well as the detection of asymptomatic atherosclerosis, reclassifies low-moderate CVD risk individuals into higher risk categories, contributing to tailored therapeutic decisions in primary prevention. However, differences in the performance of the available CVD risk assessment tools, the recommended thresholds for intervention, and the treatment targets by scientific societies introduce considerable inconsistency to the statin therapy practices. In addition, physicians’ inertia and poor patients’ adherence contribute to inadequate dyslipidemia control rates. This narrative review examines the available evidence on the current most used CVD risk assessment tools and the respective lipid-lowering recommendations, and highlights the role of targeted screening for asymptomatic atherosclerosis in terms of individualized therapy for primary prevention.

The European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) have recently released separate guidelines for the management of arterial hypertension, published less than 12 months apart. Many practicing physicians, especially in the primary care setting, might find it challenging to thoroughly read the two lengthy documents and, most importantly, might get confused in areas of discrepancies. This review compares the two sets of recommendations using the BEST framework, which focuses on Blood pressure (BP) measurement and monitoring, Establishing the diagnosis and classifying hypertension, Stratified patient assessment, and Therapeutic decisions, providing a structured overview of their areas of agreement and divergence and aiming at highlighting what the practicing physician should keep in mind. In general, the main recommendations made by the 2023 ESH and 2024 ESC guidelines regarding hypertension diagnosis and management present many similarities: office diagnostic threshold at 140/90 mmHg (multiple measurements and visits), primary role of out-of-office BP monitoring in confirming hypertension diagnosis and in follow-up of treated patients, cardiovascular (CV) risk assessment based on risk calculators and risk modifiers, initiation of drug treatment based on BP level and CV risk, treatment strategy based on steps and combination therapy, and treatment target for most patients of <130/80 mmHg.

Current European guidelines for primary atherosclerotic cardiovascular disease (ASCVD) prevention recommend using Systematic Coronary Risk Evaluation 2 (SCORE2) algorithms for risk classification and decision-making. For the Greek population, an updated model - HellenicSCORE II+ - has been developed. This cross-sectional study compared SCORE2 versus HellenicSCORE II+ in detecting preclinical carotid atherosclerosis. Middle-aged (40-69 years) individuals from the general population without ASCVD, were invited to participate on a voluntary basis in screening programs in 3 municipalities of Attica, Greece (2023-2025). Handheld carotid ultrasonography was performed and carotid plaque score (CPS) was calculated by summing points allocated to the number/height of plaques. A total of 965 individuals were analyzed [mean age 57.1±8.0 (SD) years, men 43.2%, body mass index 27.6±4.7 kg/m², smokers 27.8%, diabetes 7%, antihypertensive/lipid-lowering drug treatment 41.6%/46.5% respectively, SCORE2 5.2±3.4%, HellenicSCORE II+ 3.7±2.4%]. Participants classified as low-moderate/high/very-high ASCVD risk were 50.9%/43.3%/5.8% according to SCORE2, 74.4%/23%/2.6% with HellenicSCORE II+ and 55.6%/36.4%/8% with CPS. The agreement between SCORE2 and HellenicSCORE II+ was 67.2% (kappa 0.37, P<0.01), whereas between CPS and SCORE2/HellenicSCORE II+ 57.6%/56.2% (kappa 0.24/0.13, P<0.01 for each, P<0.01 for comparison). Receiver operating characteristic curve analysis demonstrated similar discrimination of SCORE2/HellenicSCORE II+ for detecting carotid atherosclerosis (AUC 0.74, 95% confidence intervals 0.71-0.78 and 0.71, 0.68-0.74 respectively, P=NS for comparison). SCORE2 classified a higher proportion of participants as high/very-high ASCVD risk compared with HellenicSCORE II+. Both models demonstrated moderate discrimination for detecting carotid plaque burden, highlighting the need for carotid imaging in refining ASCVD risk.