The most appropriate option for this patient with intermediate cardiovascular risk is to obtain an additional factor to help clarify risk to guide therapy, such as a coronary artery calcium (CAC) score. Assessment for risk of atherosclerotic cardiovascular disease (ASCVD) is an important component of primary prevention. Several risk assessment tools for ASCVD are available, with the Framingham risk score being the most commonly used. The Pooled Cohort Equations are a new risk assessment instrument developed from multiple community-based cohorts (including the Framingham study) that includes a broader range of variables and endpoints than the Framingham score when evaluating 10-year ASCVD risk. Its use as a primary risk assessment tool was recommended in the 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk. Using this method, a 10-year risk of ASCVD of below 5% is considered low risk, 5% to below 7.5% is classified as intermediate risk, and 7.5% or above is designated as high risk. For patients with intermediate risk, such as this patient with a risk of 6%, additional factors may be helpful in further refining risk assessment by identifying patients who may benefit from a more aggressive prevention strategy. Factors that can help further define risk include:

• CAC score greater than 300 or greater than 75% for age
• High-sensitivity C-reactive protein level (hsCRP) above 2 mg/L
• Ankle-brachial index below 0.90
• LDL cholesterol level 160 mg/dL (4.14 mmol/L) or higher or other evidence of genetic hyperlipidemia
• Family history of premature ASCVD with onset younger than 55 years in a first-degree male relative or younger than 65 years in a first-degree female relative

The results of the CAC score may help inform the individual patient-physician discussion in this intermediate-risk patient.

In this active construction worker who is asymptomatic, the pretest probability of finding ASCVD is low; because of the increased rate of false-positive test results in low-risk patients, stress testing is not recommended. The use of stress testing to diagnose ASCVD in asymptomatic persons does not reduce mortality. Appropriate risk factor modification, however, does have the potential to reduce cardiovascular risk and mortality.

There is no evidence that further lowering of blood pressure results in decreased cardiovascular risk in low- and intermediate-risk patients, such as this one; however, the Systolic Blood Pressure Intervention Trial (SPRINT) recently showed that risk of cardiovascular events and all-cause mortality were significantly reduced in hypertensive adults aged 50 years and older with increased cardiovascular risk (existing cardiovascular disease, chronic kidney disease, 10-year Framingham cardiovascular risk score >15%, or age 75 years or older) who were treated to a target systolic blood pressure of 120 mm Hg (SPRINT Research Group et al, 2015). Guidelines do not yet reflect the results of SPRINT, and the eighth report of the Joint National Committee currently recommends treating hypertensive patients aged 60 years or younger to a goal blood pressure of less than 140/90 mm Hg. Therefore, an increase in this patient's lisinopril dosage would not be appropriate according to current guidelines.

Although studies of the mechanisms of atherosclerosis suggest that antioxidant therapy might be protective against development of ASCVD, studies have failed to show a benefit of antioxidants as a primary prevention intervention. The use of vitamins A, C, or E, alone or in combination, is therefore not recommended to decrease cardiovascular risk.