Analysis of current approaches and tools for cardiovascular risk assessing in young and middle-aged adults

ABSTRACT. Early, adequate cardiovascular risk stratification as part of primary prevention is most justified in young and middle-aged individuals due to its maximum clinical benefits. An analysis of the main actual risk assessment tools designed to identify and correct cardiovascular risk factors in the 20–59 age group is performed. The majority of existing risk assessment systems are most effective within the population groups for which they were developed; their informativeness decreases when used in other populations, even after calibration based on current morbidity and mortality rates.  Furthermore, significant differences can be observed in the structure and predictive value of cardiovascular risk factors in age cohorts under and over 40 years. Despite the potential of artificial intelligence and machine learning to improve the accuracy of risk stratification for any age group, the widespread implementation of these methods is limited by the lack of sufficient evidence of their clinical superiority over traditional approaches to personalized prognosis in primary prevention. A solution to this problem may lie in validating existing risk stratification models for target patient groups, as well as increasing their informativeness by expanding the set or varying the range of cardiovascular risk markers. It is also important to consider the availability of assessment methods in clinical practice, particularly in primary healthcare.

For citation: Boeva OI, Oleynikova VD, Larina VN, Rzhevskaya EV, Petrova DN, Baibuldin IR. Analysis of the current approach and tools for cardiovascular risk assessing in young and middle-aged adults. Therapy (Moscow). 2026;12(5S):75–85.
https://dx.doi.org/10.18565/therapy.2026.5-s5.75-85

INTRODUCTION

Against the background of increasing cardiovascular (CV) morbidity, the mean age of patients seeking cardiovascular care in the Russian Federation is 44.6 ± 7.5 years, while the annual increase in the proportion of acute cardiovascular conditions among individuals younger than 50 years is 1.5–2.5% [1, 2]. The Global Burden of Disease Study likewise indicates an increasing prevalence of cardiovascular disease (CVD) among young and middle-aged adults in recent decades [3]. The trend toward an earlier onset of atherosclerotic cardiovascular disease (ASCVD) underscores the need for timely prevention.

Cardiovascular risk in adulthood, including early adulthood, has been shown to be associated with subsequent lifetime CVD mortality [4–6]. However, national programs for the detection and management of risk factors in apparently healthy individuals older than 40 years have not demonstrated an effect on cardiovascular outcomes [7]. Therefore, early and appropriate CV risk stratification through systematic and opportunistic screening is particularly important for identifying relatively young individuals who have no established CVD caused by atherosclerosis or its complications but do have risk factors, most of which are modifiable. This cohort is likely to derive the greatest benefit from early primary prevention interventions, including through a reduction in the cumulative burden of atherosclerosis [8, 9]. The absolute number of deaths in the population is known to be higher in low- and moderate-risk groups because these groups are much larger [10]. This approach is most effective and economically justified in populations with high cardiovascular risk, including the Russian population [11, 12]. Under Russian law, periodic health checkups and preventive medical examinations, which include screening for cardiovascular risk factors and asymptomatic CVD, are conducted every 3–5 years in individuals aged 18–39 years and annually in those aged 40–65 years [13].

According to the 2022 Russian National Guidelines on Cardiovascular Prevention, individual CV risk assessment allows a patient to be assigned to one of the following categories:

• apparently healthy individuals (at low or moderate risk);
• individuals with arterial hypertension (AH) but no documented ASCVD;
• patients with established ASCVD;
• patients with type 2 diabetes mellitus (T2DM);
• patients with specific risk factors, such as chronic kidney disease or familial hypercholesterolemia (FH).

Depending on the cardiovascular risk category, an individualized stepwise prevention strategy and an approach to correcting risk factors, pathological conditions, and/or diseases are developed and implemented. Preventive counseling and an informed discussion of risk-reduction approaches are also conducted with the patient [14].

CURRENT PRINCIPLES AND TOOLS FOR RISK ASSESSMENT IN PRIMARY CARDIOVASCULAR PREVENTION

ASCVD risk results from the interaction of a wide range of causal factors and therefore varies considerably among individuals. A combination of mildly or moderately elevated risk factors present in a substantial proportion of the population may have as great an effect on outcomes, particularly after prolonged exposure, as a single markedly elevated risk factor. For this reason, CV risk stratification and the selection of a primary prevention strategy in modern healthcare systems rely on purpose-built risk estimation tools – risk scores. These calculators incorporate combinations of risk factors that are most relevant to a given population because of their contribution to cardiovascular morbidity and mortality, as established in epidemiological studies [7]. Contemporary risk scores for primary cardiovascular prevention were developed at different times and for different healthcare systems using studies conducted in regions that varied in racial and ethnic composition and population-level CV risk. These tools target different age groups and differ in their prediction horizon, predicted outcomes, and included CV risk factors (Table 1).

In addition to traditional parameters (age, sex, smoking, blood pressure, abnormal lipid or glucose metabolism, overweight, and obesity), cardiovascular risk is influenced by interacting environmental factors (air pollution, noise, and high temperatures), psychosocial factors (mental well-being, chronic stress, low socioeconomic status, and optimism), genetic factors (a family history of CVD and membership in a high-risk ethnic or racial group), and other factors (a history of preeclampsia or menopause before 40 years of age, migraine, low-grade systemic inflammation, systemic connective tissue diseases, and other concomitant conditions, including comorbidities), which are accounted for indirectly [15–21].

Adding novel risk factors to traditional ones may help reclassify CV risk when the estimate is close to a decision threshold and place the patient in a more appropriate category. Widespread use of this approach ...

O.I. Boeva, V.D. Oleinikova, V.N. Larina, D.N. Petrova