• Primary prevention: Estimating 10-year risk for the first "hard" ASCVD event (nonfatal MI, CHD death, or fatal/nonfatal stroke).
• Decision support for initiating statin therapy in asymptomatic adults.
• Guidance for blood pressure targets and aspirin use in primary prevention.

• Patients with established ASCVD (Secondary prevention rules apply).
• Patients with LDL-C ≥ 190 mg/dL (Statins indicated regardless of score).
• Pregnancy (Statins are generally contraindicated).

The Pooled Cohort Equations (PCE) utilize a sex- and race-specific Cox proportional hazards model. Unlike the older Framingham score, the PCE specifically includes stroke as an endpoint and accounts for the higher baseline risk observed in African American populations.

• Family history of premature ASCVD (Males < 55y; Females < 65y).
• Persistently elevated LDL-C ≥ 160 mg/dL.
• Chronic Kidney Disease (eGFR 15–59 mL/min/1.73m2).
• Metabolic Syndrome (increased waist circ, TG > 150, low HDL, HTN, elevated glucose).
• Inflammatory conditions (Lupus, RA, Psoriasis, HIV/AIDS).
• History of premature menopause (before age 40) or pregnancy-related conditions (Preeclampsia).
• High-risk ethnicity (e.g., South Asian ancestry).

• Persistent elevations of Triglycerides (≥ 175 mg/dL).
• High-sensitivity C-reactive protein (hsCRP) ≥ 2.0 mg/L.
• Lipoprotein(a) ≥ 50 mg/dL or 125 nmol/L.
• ApoB ≥ 130 mg/dL.
• Ankle-Brachial Index (ABI) < 0.9.

• Low Risk (< 5%): Emphasize lifestyle (Heart-healthy diet, exercise, no tobacco).
• Borderline Risk (5–7.4%): Discuss moderate-intensity statin ONLY if risk enhancers are present.
• Intermediate Risk (7.5–19.9%): Clinician-patient discussion; initiate moderate-intensity statin to reduce LDL-C by 30–49%.
• High Risk (≥ 20%): Initiate high-intensity statin therapy to reduce LDL-C by ≥ 50%.

The PCE was a response to the limitation of the Framingham Heart Study, which was primarily composed of White participants. By pooling data from the Framingham, ARIC, CARDIA, and CHS studies, the ACC/AHA created a tool that better reflected the diverse demographics of the modern United States.