App Review: The ACC-AHA ASCVD Risk Estimator

The 2013 AHA/ACC cholesterol guidelines¹ redefined management of lipids and brought with them the Atherosclerotic Cardiovascular Disease (ASCVD) risk “estimator” online companion tool. Note the purposeful use of the term “estimator,” rather than “calculator,” a choice intended to convey the point that the result is an approximation of ASCVD risk rather than an exact determination of risk in an individual. Much has been written about the ramifications of the specific changes detailed in these new guidelines. Love them or hate them, these guidelines have changed practice.

The equation at the heart of the estimator was derived from a Pooled Cohort of NIH-sponsored studies (ARIC, CHS, CARDIA, Framingham Original, and Framingham Offspring)¹ and attempts to estimate risk for fatal and non-fatal MI and stroke for individuals using sociodemographics and traditional risk factors. Unlike counting up the risk points from ATP III, there is no way that you are going to be able to get to the risk estimate in your head. Fortunately, you don’t have to.

The ACC/AHA ASCVD Risk Estimator app was developed by the American College of Cardiology foundation and first released in early 2014. It is available for Apple and Android smart phones and tablets for free at their respective online stores. This user-friendly app is geared to both medical professionals and patients. It’s designed to help provide a sense of 10-year ASCVD risk for patients aged 40-79 years and lifetime ASCVD risk for those aged 20-59 years. It’s engineered to be efficient and intuitive, which means it can be incorporated into a clinical encounter. Let's take a closer look.

On opening the app, you are on the Estimator screen. Enter the sex, age, race, total cholesterol, HDL cholesterol, and SBP, then indicate whether the patient is on HTN therapy, has a history of DM, or is a smoker. Data entry is quick, unless you need to use a third-party calculator to convert to SI units, which aren’t supported in the current version of the app. (You can also be slowed down a bit if you have to manually delete information from the last patient as there is no reset button.) After completing data entry, up pops an estimation of 10-year and lifetime risk. Importantly, it also presents, for comparison, the estimated risk for a similar person with optimized risk factors.

Importantly, the risk estimation is linked to clinical recommendations from the AHA/ACC guidelines. The Clinicians tab is essentially an FAQ of ASCVD risk estimation. Does your patient qualify for moderate-intensity statin and you want to review each of the possible medication choices? Select ‘Intensities of Statin Therapy’ to see what you can use. Not sure about the latest recommendations for lifestyle changes when initiating statin therapy? Check out ‘Lifestyle Recommendations’ for information on diet, weight management, physical activity, and smoking cessation.

The Patients tab provides helpful resources from the ACC’s CardioSmart patient portal with educational overviews of ASCVD as well as information on behavioral changes like weight loss and dietary modifications. This feature isn’t designed so that patients can create a profile that will save their ASCVD risk score or get directed advice. Still, motivated patients may find this part useful.

For those interested in taking a deeper dive into the complexities underlying the ASCVD Pooled Cohort Equations, the website www.ClinCalc.com has some excellent visualization tools, including an animated 3D graph. Using a modern browser, head to their website to learn more.

We both routinely use the ACC/AHA ASCVD Risk Estimator in our clinical practices. We find it to be a convenient tool that helps us as busy clinicians engage our patients in shared decision making and deliver guideline-based care.

References

Goff DC, 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. Published online before print November 12 2013, doi:10.1161/01.cir.0000437741.48606.98

ClinCalc.com http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

ACC ASCVD Risk Estimator http://tools.acc.org/ASCVD-Risk-Estimator/