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5 Table 5. High or Very High Risk Patient Groups Quantitative risk scoring is not necessary for initial risk assessment in patients with the following conditions a : • Diabetes mellitus, type 1 or 2 • Chronic kidney disease, stage ≥3B • LDL-C ≥190 mg/dL – severe hypercholesterolemia phenotype, which includes FH • ASCVD a Patients in these categories are all at high or very high risk for an ASCVD event and should be treated accordingly. Table 6. Sequential Steps in ASCVD Risk Assessment 1. Identify patients with either very high risk or high risk conditions. a Very High Risk a. ASCVD b. Diabetes mellitus with ≥2 other major ASCVD risk factors or end organ damage b High Risk a. Diabetes mellitus with 0-1 other major ASCVD risk factors b. Chronic kidney disease stage 3B or 4 c c. LDL-C ≥190 mg/dL (severe hypercholesterolemia phenotype) 2. Count major ASCVD risk factors. a. If 0-1 and no other major indicators of higher risk, assign to low risk category. Consider assigning to a higher risk category based on other known risk indicators, when present. b. If ≥3 major ASCVD risk factors are present, assign to high risk category. 3. If 2 major ASCVD risk factors, risk scoring should be considered, and additional testing may be useful for some patients. a. If quantitative risk scoring reaches the high risk threshold, d assign to high risk category. b. Consider assigning to high risk category if other risk indicators are present based on additional testing. c. If, based on above steps, no indication is present to assign to high risk, assign to moderate risk category. a Further risk assessment is not required aer identifying the highest applicable risk level. b End organ damage indicated by increased albumin/creatinine ratio (≥30 mg/g ), CKD, or retinopathy. c For patients with CKD stage 3B (GFR 30-44 mL/min/1.73 m 2 ) or stage 4 (GFR 15-29 mL/min/1.73 m 2 ) risk calculators should not be used because they may underestimate risk. Stage 5 CKD (or on hemodialysis) is a very high risk condition, but results from randomized, controlled trials of lipid- altering therapies have not provided convincing evidence of reduced numbers of ASCVD events in such patients. erefore, no treatment goals for lipid therapy have been defined for stage 5 CKD. d High risk threshold is defined as ≥10% using ATP III Framingham Risk Score for hard CHD (MI or CHD death), ≥15% using the 2013 Pooled Cohort Equations for hard ASCVD (MI, stroke or death from CHD or stroke), or ≥45% using the Framingham long-term (to age 80) CVD (MI, CHD death or stroke) risk calculation. Clinicians may prefer to use other risk calculators but should be aware that quantitative risk calculators vary in the clinical outcomes predicted (eg, CHD events, ASCVD events, cardiovascular mortality), the risk factors included in their calculation, and the time frame for their prediction (eg, 5 years, 10 years, or long-term or lifetime). Such calculators may omit certain risk indicators that can be very important in individual patients, provide only an approximate risk estimate, and require clinical judgment for interpretation.