A 10-year cardiovascular risk estimate may not tell the whole story in midlife.
Dr. Emily S. Lau is an assistant professor of medicine at Harvard Medical School and co-director of the Women's Heart Health Program at the Mass General Brigham Heart and Vascular Institute. She presented 'Assessing the risk: primary prevention guidelines and their application in midlife women' at The Menopause Society 2026 Annual Meeting, held October 20 to 24 in San Diego, California. Her talk was part of the plenary symposium 'Beyond the basics: cardiovascular risk, lipid management, and sex-based differences at menopause.'
Dr. Lau opened with a 48-year-old woman with a low estimated 10-year risk and a history of preeclampsia and gestational diabetes. 'A 48-year-old woman gets a tremendous risk discount simply because she's 48,' she pointed out. Low short-term risk, she argued, does not necessarily mean low prevention priority.
How the 2026 guidelines may refine cardiovascular risk assessment in midlife women
Dr. Lau used the classify, personalize, and reclassify framework of the 2026 American Heart Association and American College of Cardiology guidelines. The PREVENT equations used to classify risk also give a 30-year estimate. Because age keeps a midlife woman's 10-year estimate low, she sees the 30-year estimate as the real value.
Personalizing adds what calculators miss, such as pregnancy, which Dr. Lau called 'an incredibly effective cardiovascular stress test.' She uses these risk factors 'to add clinical context to her calculated estimate.'
When uncertainty remains, coronary artery calcium (CAC) scoring can act as a tiebreaker, though not for every midlife woman. 'The sweet spot really is in that uncertain area,' she said. And since blood pressure strongly shapes future risk, 'prevention in midlife is not simply a statin conversation.'
Why menopause may be a prevention inflection point for cardiovascular disease
Dr. Lau described menopause as a 'prevention inflection point,' when cardiometabolic health changes. Hormone therapy is not started to prevent cardiovascular disease, she said, but 'a menopause consultation is a powerful moment for us to be addressing traditional cardiovascular risk factors, regardless of whether the patient ultimately uses hormone therapy.'
Telling a woman her risk is only 2% suggests there is nothing to do, Dr. Lau said. Instead, she suggested, 'Your short-term risk is low, in part because you're 48,' while her blood pressure, low-density lipoprotein cholesterol, and pregnancy history 'suggest that you may be on a higher lifetime cardiovascular risk trajectory.' This gives the patient agency, she explained.
For her patient, the 10-year risk was about 2%, the 30-year risk 17%, and a CAC score of 121 showed coronary atherosclerosis. Dr. Lau would discuss moderate-intensity statin therapy, intensify lifestyle and blood pressure management, and treat vasomotor symptoms. Assessing risk in midlife, she concluded, means asking what a woman's trajectory is and what can be changed now.
Key takeaway: Midlife is an intervention window, and low 10-year risk can coexist with substantial longer-term risk.
CAC, coronary artery calcium.