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Background According to the latest ESC Guidelines for chronic coronary syndromes (CCS), patients who suffered an acute coronary syndrome (ACS) pass to a chronic stable phase after one year. In these patients the estimated 10-year risk for recurrent cardiovascular (CV) events varies considerably. We estimated this risk and the expected risk reduction after optimal control. Methods We applied the SMART risk score in 211 patients one year after an ACS to estimate the 10-year risk for recurrent CV events (subsequent non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death). We assessed the distribution of the estimated risk and the potential risk reduction that might be achieved with an optimal guideline-directed management of modifiable risk factors (systolic blood pressure, low-density lipoprotein cholesterol, smoking and body mass index). Results In our cohort, the median SMART score was 16% [interquartile range (IQR), 9.5–26]. If all modifiable risk factors met guideline-recommended targets, median SMART risk score would be 9.4% (IQR, 5.9–17.1), with 52% of the patients at a 10-year risk &amp;lt;10%, while 10% and 11% at 20–30% and &amp;gt;30% risk respectively. The total median reducible risk was 4.7% (IQR, 1.7–8.8). Conclusions The SMART score had a wide distribution among patients with CCS. Noteworthy, one out of five patients will remain at a &amp;gt;20% 10-year risk, even with optimal risk factors management, clearly underlining that residual risk is an unmet clinical issue, which demands individualized patient care. Baseline and total residual risk score Funding Acknowledgement Type of funding source: None

Risk for recurrent cardiovascular events and expected risk reduction with optimal treatment one year after an acute coronary syndrome