The American College of Cardiology and the American Heart Association 2018 Cholesterol Guideline proposed the new classification of “very high-risk” atherosclerotic cardiovascular disease (ASCVD) (multiple ASCVDs or 1 ASCVD plus $2 high-risk conditions) to guide intensive secondary prevention. This guideline takes into account reduced glomerular filtration rate (GFR) as a high-risk condition, but not albuminuria, a measure of kidney damage, that is more strongly associated with cardiovascular outcomes than reduced GFR. Importantly, the assessment of albuminuria is already recommended in patients with diabetes and hypertension, and thus, data of albuminuria are readily available in many patients with ASCVD. We explored whether urine albumin-to-creatinine ratio (ACR) is independently associated with adverse outcomes and can improve risk prediction in persons with ASCVD beyond the high-risk conditions in the guideline
