Integrated CV Risk
Nudge Tool

SCORE2 + Imaging + Biology
VAT · FAI · Lp(a) · HDL signal
SCVC v1.0 · April 2026
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1 Baseline — SCORE2 / CT tier

Enter the result from the SCORE2 calculator or the ESC CVD Risk app. If a CT tier has already been assigned by the SCORE2 + CAC + CAD-RADS calculator, select that as the baseline — it is the floor and cannot be reduced by the nudge score.

CT tier floor rule: CT high risk and CT ultra-high risk tiers assigned by the SCORE2/CAC/CAD-RADS calculator are always the minimum. The nudge score can only move the classification upward from a CT floor — never downward. If CT ultra-high risk is already assigned, no further escalation from nudge modifiers is possible; qualifiers and clinical actions still apply.

Baseline category SCORE2 % (optional, for record)

2 Major upward modifiers — +2 each

Any single major modifier may justify reclassification as high-risk phenotype. Tick all that apply.

Imaging / disease expression

CAC ≥100 or ≥75th centile for age/sex +2 Obstructive CAD on CTCA (stenosis ≥50% or FFR-CT ≤0.80) +2 High-risk plaque features (LRNC, positive remodelling, spotty Ca²⁺, napkin-ring sign) +2

Biological / genetic

Markedly elevated Lipoprotein(a) — typically Lp(a) >200 nmol/L (or >100 nmol/L + other RF) +2 Familial hypercholesterolaemia phenotype (Dutch Lipid Clinic Score ≥6 or genetic confirmation) +2

Clinical severity

Diabetes with target organ damage (microalbuminuria, retinopathy, neuropathy, or CKD ≥3) +2

2b Moderate upward modifiers — +1 each (stackable; 2–3 ≈ 1 major)

Imaging / disease expression

CAC 1–99 (any detectable calcified plaque) +1 Non-obstructive plaque on CTCA (plaque present, stenosis <50%) +1 Elevated FAI-Score (CaRi-Heart ≥50th centile on any vessel) +1

Biological / clinical

Premature family history of CVD (1st-degree relative: men <55, women <65) +1 Early menopause (<45 years) +1 CKD stage ≥3 (eGFR <60) — if not already counted in major modifiers +1 Elevated ApoB or non-HDL above target for assigned risk tier +1 Persistent elevated triglycerides (>2.3 mmol/L) or low HDL (<1.0 M / <1.2 F mmol/L) +1

2c Biological signals — interpret carefully

Very high HDL-C — biological signal, not protection

Very high HDL-C — men ≥2.5 mmol/L · women ≥3.0 mmol/L. U-shaped risk curve: very high HDL may reflect dysfunctional HDL biology. Review for alcohol excess, liver disease, hyperthyroidism, medications, or genetic cause. +1 signal

Very high HDL never offsets imaging disease, LDL burden, or genetic risk. Assign +1 as a biological signal only. Always trigger a review for underlying cause.

2d Metabolic / adiposity load — VAT & VAT-years (cap +2 total)

High current VAT — waist:height >0.5 or elevated VATI on CT body composition +1 VAT-years moderate — 5–10 years of elevated visceral adiposity +1 VAT-years high — >10–15 years of elevated visceral adiposity (cumulative metabolic burden) +2

VAT total capped at +2 maximum — prevents double-counting of metabolic risk. Current VAT + VAT-years combined cannot exceed +2.

2e Downward modifiers — −1 each (apply cautiously; short-term risk only)

These reduce current short-term risk only. They do NOT erase lifetime risk, genetic risk, or imaging-confirmed disease.

CAC = 0 (very low near-term calcified plaque risk) −1 Normal CTCA — no plaque, no stenosis (CAD-RADS 0) −1 Favourable metabolic profile — normal weight, insulin-sensitive, low TG, high HDL in normal range −1 High lifetime fitness — high aerobic capacity (VO2max), consistent vigorous exercise history −1 FAI-Score <50th centile on all vessels (CaRi-Heart report) — no significant pericoronary inflammation −1

Fitness does NOT negate plaque, high CAC, Lp(a) elevation, or FH. Downward modifiers cannot reduce score below 0 if imaging disease is present.

This nudge tool is designed for use alongside ESC SCORE2 at Surrey Cardiovascular Clinic. It integrates imaging (CAC, CTCA, FAI), biological (Lp(a), FH, HDL), metabolic (VAT, VAT-years), and resilience (fitness) factors into a structured clinical phenotype. It does not replace clinical judgement. Override rules always apply — imaging-confirmed disease and genetic risk cannot be erased by protective factors. Source: SCVC Integrated CV Risk Framework v1.0, April 2026. · Full clinical reference →