PL Detail-Document #300102

This PL Detail-Document gives subscribers

additional insight related to the Recommendations published in
PHARMACISTS LETTER / PRESCRIBERS LETTER
January 2014


More. . .
Copyright 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com


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 youre 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.

A list of websites with cardiovascular risk calculator apps for smartphones follows this chart
Calculator Comments
2013 Pooled Cohort Equations
Cardiovascular Risk Calculator

http://my.americanheart.org/cvriskcalculator









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.

(PL Detail-Document #300102: Page 2 of 5)

More. . .
Copyright 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com



Calculator Comments
Framingham
Coronary Heart Disease 10-year Risk

http://www.framinghamheartstudy.org/risk-
functions/coronary-heart-disease/10-year-
risk.php
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

http://www.framinghamheartstudy.org/risk-
functions/cardiovascular-disease/10-year-
risk.php

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.
National Cholesterol Education Program
(NCEP) Adult Treatment Panel III (ATP
III) risk assessment tool based on
Framingham Heart Study

http://cvdrisk.nhlbi.nih.gov/calculator.asp


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



Reynolds Risk score

http://www.reynoldsriskscore.org

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 Womens 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



(PL Detail-Document #300102: Page 3 of 5)

More. . .
Copyright 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com



Calculator Comments
American Diabetes Associations Diabetes
My Health Advisor risk assessment tool

http://www.diabetes.org/living-with-
diabetes/complications/diabetes-phd/

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

http://www.aricnews.net/riskcalc/html/
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




UKPDS Risk Engine

http://www.dtu.ox.ac.uk/riskengine/
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



Canadian Diabetes Association tool for
identifying diabetes patients who require
vascular protective medication

http://guidelines.diabetes.ca/VascularProtectio
n/RiskAssessment




For patients with diabetes.
Not a quantitative tool; identifies high-risk patients for whom certain pharmacologic interventions
are recommended (e.g., ACEI, ARB, statin).
(PL Detail-Document #300102: Page 4 of 5)

More. . .
Copyright 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com



Calculator Comments
McGill Cardiovascular Health
Improvement Program for assessing a
patients Cardiovascular Age

http://www.chiprehab.com

Use to explain the patients 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 (http://statcoder.wordpress.com/category/cardiovascular-risk/) provides 2013 Pooled Cohort Equations CV Risk Calculator, ATP III,
Framingham, and Reynolds for iPhone, iPod Touch, and iPad (free).
Calculate (http://www.qxmd.com/specialty/medicine/cardiology-medical-apps-iphone-blackberry-android) includes Framingham and Reynolds
for iPhone, iPod Touch, iPad, Blackberry, and Android (free).
Archimedes 360 (http://www.skyscape.com/estore/store.aspx?category=26) provides over 200 medical calculators including Framingham and
ATP III for iPhone, iPod Touch, iPad, Blackberry, Android, and Windows Mobile Smartphone (less than $25).
2013 Pooled Cohort Equations CV Risk Calculator (https://itunes.apple.com/us/app/2013-pooled-cohort-equations/id754470890?mt=8) for
iPhone, iPod Touch, iPad (free).
ClinCalc (http://clincalc.com/) includes a number of online calculators, as well as 2013 Pooled Cohort Equations CV Risk Calculator for
iPhone/iPad and Android (free).
ScyMed (https://play.google.com/store/apps/developer?id=ScyMed+Inc.) has 2013 Pooled Cohort Equations CV Risk Calculator for Android
($1.00).






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.





(PL Detail-Document #300102: Page 5 of 5)

Subscribers to the Letter can get PL Detail-Documents, like this one,
on any topic covered in any issue by going to www.PharmacistsLetter.com,
www.PrescribersLetter.com, or www.PharmacyTechniciansLetter.com

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)

References
1. Sisson E, Van Tassell BW. Dyslipidemias: updates
and new controversies. In: Richardson M, Chant C,
Cheng JWM, et al., editors. Pharmacotherapy self-
assessment program, 7
th
ed. Cardiology. Lenexa,
KS: American College of Clinical Pharmacy; 2010.
p. 25-42.
2. 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;106:38891.
3. 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 2002.
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3fu
ll.pdf. (Accessed December 3, 2013).
4. Viera AJ, Sheridan SL. Global risk of coronary heart
disease: assessment and application. Am Fam
Physician 2010;82:265-74
5. Sheridan S, Pignone M, Mulrow C. Framingham-
based tools to calculate the global risk of coronary
heart disease: a systematic review of tools for
clinicians. J Gen Intern Med 2003;18:1039-52.
6. 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;121:2694-701.
7. DAgostino RB, Grundy S, Sullivan LM, et al.
Validation of the Framingham Coronary Heart
Disease Prediction Scores. JAMA 2001;286:180-7.
8. 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;25:1145-51.
9. Genest J, McPherson R, Frohlich J, et al. 2009
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;25:567-79.
10. 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;31:1670-1.
11. 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;154:80-6.
12. Grundy SM, Pasternak R, Greenland P, et al.
Assessment of cardiovascular risk by use of multiple-
risk-factor assessment equations: a statement for
healthcare professionals from the American Heart
Association and the American College of Cardiology.
Circulation 1999;100:1481-92.
13. 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;54:1209-27.
14. DAgostino RB, Vasan RS, Pencina MJ, et al.
General cardiovascular risk profile for use in primary
care: the Framingham Heart Study. Circulation
2008;117:743-53.
15. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013
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:10.1161/01.cir.0000437741.48606.98/-
/DC1.
16. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013
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:10.1161/01.cir.0000437738.63853.7a.


Cite this document as follows: PL Detail-Document, Common Cardiovascular Risk Calculators. Pharmacists
Letter/Prescribers Letter. January 2014.


Evidence and Recommendations You Can Trust


3120 West March Lane, Stockton, CA 95219 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249
Copyright 2014 by Therapeutic Research Center