Background : cardiovascular diseases (CVD) remain the leading global cause of mortality. Approximately 50% of the CVD burden is attributable to five modifiable risk factors, including dyslipidemia. Effective management of low-density lipoprotein cholesterol (LDL-C) through accurate cardiovascular (CV) risk stratification is fundamental to prevention. However, in daily practice, significant variability exists in how clinicians assess CV risk and determine appropriate LDL-C targets, potentially leading to suboptimal patient care.

Objective : this cross-sectional survey aimed to evaluate the consistency and alignment with current guidelines of CV risk assessment and LDL-C target selection among clinicians working at Avicenne University Hospital, Assistance Publique-Hôpitaux de Paris (Bobigny, France), when presented with diverse and challenging clinical scenarios, that formal risk calculation tools cannot assess.

Methods : between September and November 2025, a questionnaire-based cross-sectional survey was conducted at Avicenne University Hospital. Thirty doctors and residents from five departments (Internal Medicine, Vascular-Thoracic Surgery, Cardiology, Geriatrics, Endocrinology) participated. They were presented with six clinical vignettes designed to probe CV risk assessment in complex contexts such as heart failure, atherosclerotic cardiovascular disease (ASCVD), recurrent events, and chronic kidney disease. Responses were categorized into CV risk groups (Low to Extreme) based on the proposed LDL-C target, in accordance with the 2025 ESC/EAS dyslipidemia guidelines. Responses without a specific target were classified as "No category."

Results : analysis revealed significant heterogeneity in responses. The "No category" response was the most frequent overall (29.4% of all answers), indicating substantial clinician uncertainty. Key discrepancies from guidelines included: high uncertainty (43.3% "No category") in assigning risk after heart failure; underestimation of risk in confirmed ASCVD (most answers were Moderate or High risk, not Very High); reluctance to use the Extreme-risk category (<40 mg/dL) for recurrent events; and insufficient recognition of moderate CKD as a High-risk factor. Vascular surgeons most frequently gave "No category" answers (54.8% of their responses) however, there was no statistically significant difference in the proportion of “No category” responses across departments (p=0.093).

Conclusion : this survey identified a notable gap between guideline recommendations and clinical practice in CV risk assessment at the hospital level. Clinicians demonstrated a tendency to underestimate risk in key areas like ASCVD and CKD, and exhibited significant uncertainty in complex scenarios such as heart failure and recurrent events. These findings underscore the need for targeted educational initiatives and strategies to promote more consistent, guideline-concordant CV risk stratification to optimize preventive therapy.