Cardiovascular risk prediction: the old has given way to the new but at what risk-benefit ratio? Joseph Yeboah Heart and Vascular Center of Excellence, Wake Forest University School of Medicine, Winston-Salem, NC, USA Abstract: The ultimate goal of cardiovascular risk prediction is to identify individuals in the population to whom the application or administration of current proven lifestyle modifications and medicinal therapies will result in reduction in cardiovascular disease events and minimal adverse effects (net benefit to society). The use of cardiovascular risk prediction tools dates back to 1976 when the Framingham coronary heart disease risk score was published. Since then a lot of novel risk markers have been identified and other cardiovascular risk prediction tools have been developed to either improve or replace the Framingham Risk Score (FRS). In 2013, the new atherosclerotic cardiovascular disease risk estimator was published by the American College of Cardiology and the American Heart Association to replace the FRS for cardiovascular risk prediction. It is too soon to know the performance of the new atherosclerotic cardiovascular disease risk estimator. The risk-benefit ratio for preventive therapy (lifestyle modifications, statin +/− aspirin) based on cardiovascular disease risk assessed using the FRS is unknown but it was assumed to be a net benefit. Should we also assume the risk-benefit ratio for the new atherosclerotic cardiovascular disease risk estimator is also a net benefit? Keywords: risk prediction, prevention, cardiovascular disease