Common Cardiovascular Risk Calculators

Transcription

1 PL Detail-Document # This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER January 2014 Common Cardiovascular Risk Calculators Risk calculators are used to target therapies toward patients who will get the most benefit from them. They can also help spare low-risk patients from adverse effects and costs of unnecessary therapy. 1 The American Heart Association states that adults 40 to 79 years of age should generally have their heart disease risk calculated every four to six years. 2,16 Risk influences decisions to institute primary prevention interventions such as daily low-dose aspirin and statins. 2,3 Use of risk calculators has not been shown to alter clinical outcomes, but it can improve prescribing and motivate patients. You can show the benefits of the lifestyle changes and drug therapies you re recommending. Consider presenting risk as percentages as well as numbers of persons per 1000 over a specific time period; some patients comprehend numbers per 1000 better. 4 Risk calculators are better at predicting events than just counting risk factors, 5 but they have limitations. For example, because age is a strong risk determinant, calculators may underestimate risk in young patients. 4,11,12 To the other extreme, risk calculators can misidentify elderly patients as targets for aggressive pharmacotherapy. 12 Most calculators can be used in older individuals, but keep in mind that those 65 years and older may have been underrepresented in the cohorts from which the calculators were derived. 13 Clinical judgment is therefore especially important in making treatment decisions in the elderly. 12 In addition, some calculators are more or less appropriate for certain populations than others (e.g., patients with diabetes). The following chart provides links to several risk calculators for North Americans, and provides information to help you choose the most appropriate calculator for a given patient. ASCVD Risk Estimator Plus A list of websites with cardiovascular risk cal culator apps for smartphones follows this chart Incorporates the original ASCVD Risk Estimator plus the 2016 Million Hearts Longitudinal ASCVD Risk Assessment Tool and new guideline recommendations. 17 Maintains the core functionality of the original ASCVD Risk Calculator; users can still calculate the patient s 10-year ASCVD risk and get guideline-based recommendations for statin therapy. Can be used to project the benefit of specific risk-lowering interventions (statins, antihypertensives, aspirin, etc), and update and track change in risk over time based on the patient's actual response to interventions. Provides recommendations from multiple ACC/AHA guidelines (e.g., blood pressure, lifestyle, etc). Initial 10-year ASCVD risk is calculated via the Pooled Cohort Equation. The updated 10-year ASCVD risk at follow-up visits and projected 10 -year ASCVD risk values are derived from the 2016 Million Hearts Longitudinal Risk Assessment Tool. Therapy advice is derived from ACC/AHA guidelines regarding cholesterol, lifestyle, and high blood pressure, and is supplemented by the Million Hearts Longitudinal Risk Assessment User Guide.

2 (PL Detail-Document #300102: Page 2 of 6) 2013 Pooled Cohort Equations Cardiovascular Risk Calculator (ASCVD Risk Calculator) (See the updated version of this calculator above [ASCVD Risk Estimator Plus].) Part of the 2013 ACC/AHA cholesterol guidelines to determine the need for statin therapy. 15 Calculates 10-year risk of atherosclerotic cardiovascular disease (myocardial infarction or stroke). Based on data from men (white and African American) and women, with or without diabetes, 40 to 79 years of age. To determine need for statin therapy, use for primary prevention only, for patients ages 40 to 75 with LDL 70 to 189 mg/dl (1.8 to 4.9 mmol/l). Individuals with LDL 190 mg/dl (5 mmol/l) or established heart disease already qualify for statin therapy. 16 Estimates lifetime risk of atherosclerotic cardiovascular disease in individuals 20 to 59 years of age. 15 May underestimate lifetime risk. 15 May overestimate risk (Mexican Americans, Asian Americans of East Asian ancestry) or underestimate risk (American Indians, Puerto Ricans, Asian Americans of South Asian ancestry). Not intended for use with statin-treated cholesterol. (If used with patients already on a statin, use pretreatment cholesterol value.) Replaces Framingham risk assessment. Framingham Coronary Heart Disease 10-year Risk Calculates 10-year risk of coronary heart disease. Based on data from whites 30 to 74 years of age without heart disease. Also validated in African Americans and Hispanic women. May over- or underestimate risk in other ethnic groups. 7 Less precise in patients under 30 or over 65 years of age, and in patients with diabetes, severe hypertension, or left ventricular hypertrophy. 5 Framingham General Cardiovascular Disease 10-year Risk Calculates 10-year risk of cardiovascular disease (i.e., coronary death, myocardial infarction, coronary insufficiency, angina, ischemic stroke, transient ischemic attack, peripheral artery disease, heart failure). Based on data from predominantly whites 30 to 74 years of age without CVD at baseline. 14 Separate calculators for men and women.

3 (PL Detail-Document #300102: Page 3 of 6) National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) risk assessment tool based on Framingham Heart Study Reynolds Risk score American Diabetes Association s Diabetes My Health Advisor risk assessment tool S.html?loc=dorg-mha Calculates 10-year risk for myocardial infarction and coronary death. For adults 20 years and older without heart disease or diabetes. Not recommended for patients with diabetes because ATP III considered diabetes a coronary disease equivalent. 5 However, current thinking is that not all patients with diabetes are high-risk. 6 Omits family history. Classifies 15% of adults into different risk groups than Framingham (10% higher risk, 5% lower risk). 8 Calculates 10-year risk of heart attack, stroke, or other major heart disease. For healthy patients without diabetes 45 to 80 years of age. Separate calculators for women and men. Based on data from Women s Health Study and Physicians Health Study II. 1 Includes family history and hs-crp. Reclassifies 30% of intermediate risk women and 20.2% of intermediate risk men into lower or higher risk categories vs Framingham. 1 Not validated in Canadian population. 9 Calculates 10-year risk of heart attack or stroke and 8-year risk of diabetes. Also calculates risk of diabetes complications. 10 Can be used for people with or without diabetes. Can be used for people with or without cardiovascular disease. Patients can use on their own. Designed to show how changes in lifestyle or medication can affect risk. Good choice if contemplating aspirin for primary prevention in patients with diabetes. 6 ARIC CHD Risk Calculator RC1.html Calculates 10-year risk of heart attack or coronary heart disease risk in adults. Can be used for people with or without diabetes. For people 45 to 65 years of age. Good choice if contemplating aspirin for primary prevention in patients with diabetes. 6

4 (PL Detail-Document #300102: Page 4 of 6) UKPDS Risk Engine Diabetes Canada tool for identifying diabetes patients who require vascular protective medication Based on data from the UK Prospective Diabetes Study. For patients with diabetes without known heart disease. Calculates 10-year risk estimates for fatal and nonfatal coronary heart disease, fatal coronary heart disease, fatal and nonfatal stroke, and fatal stroke. Good choice if contemplating aspirin for primary prevention in patients with diabetes. 6 For patients with diabetes. Not a quantitative tool; identifies high-risk patients for whom certain pharmacologic interventions are recommended (e.g., ACEI, ARB, statin). n/riskassessment McGill Cardiovascular Health Improvement Program for assessing a patient s Cardiovascular Age (Canada) Use to explain the patient s cardiovascular risk to them and how it can be improved. Can be used to show patients how risk improves with treatment. Some Cardiovascular Risk Calculator Apps for Smartphones Statcoder ( provides 2013 Pooled Cohort Equations CV Risk Calculator, ATP III, Framingham, and Reynolds for iphone, ipod Touch, and ipad (free). Calculate ( includes Framingham and Reynolds for iphone, ipod Touch, ipad, Blackberry, and Android (free). Archimedes 360 ( provides over 200 medical calculators including Framingham and ATP III for iphone, ipod Touch, ipad, Blackberry, Android, and Windows Mobile Smartphone (less than $25) Pooled Cohort Equations CV Risk Calculator ( for iphone, ipod Touch, ipad (free). ClinCalc ( includes a number of online calculators, as well as 2013 Pooled Cohort Equations CV Risk Calculator for iphone/ipad and Android (free). ScyMed ( has 2013 Pooled Cohort Equations CV Risk Calculator for Android ($1.00).

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6 (PL Detail-Document #300102: Page 6 of 6) Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication. Project Leader in preparation of this PL Detail- Document: Melanie Cupp, Pharm.D., BCPS (Original November 2010); Stacy A. Hester, R.Ph., BCPS, Assistant Editor (January 2014 update); last modified May References 1. Sisson E, Van Tassell BW. Dyslipidemias: updates and new controversies. In: Richardson M, Chant C, Cheng JWM, et al., editors. Pharmacotherapy selfassessment program, 7 th ed. Cardiology. Lenexa, KS: American College of Clinical Pharmacy; p Pearson TA, Blair SN, Daniels SR, et al. American Heart Association Science Advisory and Coordinating Committee. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation 2002;106: National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Final Report. September ll.pdf. (Accessed December 3, 2013). 4. Viera AJ, Sheridan SL. Global risk of coronary heart disease: assessment and application. Am Fam Physician 2010;82: Sheridan S, Pignone M, Mulrow C. Framinghambased tools to calculate the global risk of coronary heart disease: a systematic review of tools for clinicians. J Gen Intern Med 2003;18: Pignone M, Alberts MJ, Colwell JA, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Circulation 2010;121: D Agostino RB, Grundy S, Sullivan LM, et al. Validation of the Framingham Coronary Heart Disease Prediction Scores. JAMA 2001;286: Gordon WJ, Polansky JM, Boscardin WJ, et al. Coronary risk assessment by point-based vs equation-based Framingham models: significant implications for clinical care. J Gen Intern Med 2010;25: Genest J, McPherson R, Frohlich J, et al Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult-2009 recommendations. Can J Cardiol 2009;25: Stern M, Williams K, Eddy D, Kahn R. Validation of prediction of diabetes by the Archimedes model and comparison with other predicting models. Diabetes Care 2008;31: Berry JD, Lloyd-Jones DM, Garside DB, Greenland P. Framingham risk score and prediction of coronary heart disease death in young men. Am Heart J 2007;154: Grundy SM, Pasternak R, Greenland P, et al. Assessment of cardiovascular risk by use of multiplerisk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 1999;100: Cooney MT, Dudina AL, Graham IM. Value and limitations of existing scores for the assessment of cardiovascular risk: a review for clinicians. J Am Coll Cardiol 2009;54: D Agostino RB, Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008;117: Goff DC Jr, Lloyd-Jones DM, Bennett G, et al ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013 Nov 12 [Epub ahead of print];doi: /01.cir /- /DC Stone NJ, Robinson J, Lichtenstein AH, et al ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013 Nov 12 [Epub ahead of print];doi: /01.cir a. 17. American College of Cardiology. ASCVD Risk Calculator Plus. practice-support/mobile-resources/features/2013- prevention-guidelines-ascvd-risk-estimator. (Accessed April 17, 2018).

7 (PL Detail-Document #300102: Page 7 of 6) Cite this document as follows: PL Detail-Document, Common Cardiovascular Risk Calculators. Pharmacist s Letter/Prescriber s Letter. January Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA ~ TEL (209) ~ FAX (209) Copyright 2014 by Therapeutic Research Center Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to or