A scale is not a diagnosis. A diagnosis of "very high risk" can be made without any scale: documented ASCVD already places a person in this category. The scale is needed for apparently healthy people without established ASCVD, diabetes, CKD or genetic/rare lipid or BP disorders.
SCORE2 (Systematic Coronary Risk Evaluation 2) is an algorithm for estimating the 10-year risk of fatal and non-fatal cardiovascular events (myocardial infarction, stroke) in apparently healthy people under 70. SCORE2-OP applies the same principle to people aged 70 and older (up to 89). Both were introduced by the 2021 ESC prevention guidelines and in the ESC/EAS 2025 focused update replaced SCORE. Class I, level B recommendation: SCORE2 in apparently healthy people <70 years without ASCVD, diabetes, CKD, genetic/rare lipid or hypertensive disorders; SCORE2-OP in apparently healthy people ≥70 years with the same exclusions.
How SCORE2 differs from SCORE, which many still remember from the "fatal risk" tables. SCORE estimated the 10-year risk of CVD death and used total cholesterol in the calculation. SCORE2/SCORE2-OP estimate fatal and non-fatal events and use non-HDL cholesterol (total cholesterol minus HDL-C) as the lipid input. The 2025 focused update emphasises: total CVD morbidity is about 2–3 times higher than fatal risk, and the multiplier depends on age and sex. Therefore the category thresholds have been recalculated: the old "1% / 5% / 10% fatal SCORE" cannot be plugged into SCORE2 as they are.
Risk categories according to Table 3 of the ESC/EAS 2025 focused update.
| Category | Who belongs |
|---|---|
| Very high risk | ASCVD documented clinically or unequivocally on imaging (including significant plaque, typically stenosis ≥50%, on coronary angiography/CT or on ultrasound of the carotid/femoral arteries, or a markedly elevated calcium score, for example CAC ≥300); diabetes with target organ damage (microalbuminuria, retinopathy, neuropathy), or ≥3 major risk factors, or early onset of long-standing type 1 diabetes (>20 years); severe CKD (eGFR <30 mL/min/1.73 m²); calculated SCORE2/SCORE2-OP ≥20% at 10 years; familial hypercholesterolaemia with ASCVD or another major risk factor |
| High risk | Markedly elevated single risk factor: total cholesterol >8 mmol/L (>310 mg/dL), LDL-C >4.9 mmol/L (>190 mg/dL) or BP ≥180/110 mmHg; FH without other major factors; diabetes without target organ damage with duration ≥10 years or with an additional factor; moderate CKD (eGFR 30–59); SCORE2/SCORE2-OP ≥10% and <20% |
| Moderate risk | Young people with diabetes (type 1 diabetes <35 years; type 2 diabetes <50 years) with duration <10 years without other factors; SCORE2/SCORE2-OP ≥2% and <10% |
| Low risk | SCORE2/SCORE2-OP <2% |
In the Kazakhstan Ministry of Health protocol No. 196/2023, Kazakhstan is classified among countries at high cardiovascular risk: the SCORE2/SCORE2-OP calibration for exactly this cluster must be applied, not the "European low-risk" table. This is stated directly in the protocol.
What the scale cannot do. It cannot be used in a person with already established ASCVD. It cannot be used in a person already receiving lipid-lowering therapy by "recalculating" the risk from current cholesterol: the algorithms were derived in cohorts without clinical ASCVD who were not receiving lipid-lowering therapy (ESC/EAS 2025). The scale underestimates familial hypercholesterolaemia: a young patient with LDL-C of 6 mmol/L may have a "moderate" 10-year score and a very high lifetime risk.
The LDL-C target levels by category were not changed by the 2025 focused update relative to ESC/EAS 2019.
| Category | LDL-C target |
|---|---|
| Low risk | <3.0 mmol/L (<116 mg/dL) |
| Moderate risk | <2.6 mmol/L (<100 mg/dL) |
| High risk | <1.8 mmol/L (<70 mg/dL) and reduction ≥50% from baseline |
| Very high risk | <1.4 mmol/L (<55 mg/dL) and reduction ≥50% from baseline |
| Recurrent vascular event within 2 years on maximally tolerated statin therapy | <1.0 mmol/L (<40 mg/dL) may be considered (an ESC/EAS 2019 provision retained in the logic of Figure 1 of the 2025 focused update) |
The "baseline" level is LDL-C without lipid-lowering therapy or an extrapolated value for someone already treated.
The boundary of the lesson. The Kazakhstan Ministry of Health protocol No. 196, in its text, gives the thresholds "low ≤1%, moderate ≥1 and ≤5%, high ≥5 and ≤10%" and at the same time names the tool SCORE2. This is an internal contradiction in the document: these cut-offs belong to the old SCORE (fatal events), not to SCORE2. In this course Table 3 of ESC/EAS 2025 is used for risk categories. When working in an organisation where protocol No. 196 is mandatory, one must open Appendix No. 2 of the protocol (the high-risk cluster SCORE2 tables themselves) and not plug the 1/5/10 thresholds into them as if they were SCORE2.
Practical conclusion. First look for conditions that by themselves confer high or very high risk (ASCVD, FH, severe CKD, "severe" diabetes, a single extreme factor). Only if there are none, calculate SCORE2/SCORE2-OP. And only after the risk category read the lipid profile as "has the target been reached".