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Funded by the Agency for Healthcare Research and Quality (AHRQ) in the U.S. Department of Health & Human Services

Discussing ASCVD Risk Score With Patients: Quantifying Treatment Effect

East Asheville Family Health Care

Dr. James Early presenting

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Heart Health NOWAdvancing Heart Health in NC Primary Care

Using the ASCVD risk score in daily practice:

- Dashboard not working

- Risk-based prescribing makes sense in the

context of better patient outcomes

- Improvement plan defined

* Rationale: Calculation of 10 year risk for patients without prior history

of CVD or event allows provider and patient to discuss risk reduction with

aspirin and/or statin therapy. Cardiovascular disease is the leading cause of

death in the US. Assessment of risk guides therapy to reduce morbidity and

mortality

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Heart Health NOWUsing the ASCVD risk score in daily practice

Initial steps

- Train MA re: patient selection

- Create field for calculated scores created in EHR

- Office workflow developed

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Heart Health NOWUsing the ASCVD risk score in daily practice

Actions Taken (1)

- For pre-appointment huddle, MA flags scheduled patients who

qualify by age parameters (40-79 years)

- If already has vascular disease diagnosis, flag removed

- Dr. Early’s computer has risk score site book marked; calculation

performed pre-visit (just prior) and printed out for patient viewing and

discussion

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Heart Health NOWUsing the ASCVD risk score in daily practice

Actions Taken (2)

- Discussion and shared decision making ensues

- Statin and / or Aspirin prescribed

- MA enters risk score in EHR structured field

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Heart Health NOWUsing the ASCVD risk score in daily practice

Results to Date

- 247 ASCVD calculations and discussions in first 4

months of plan

- 95 of these patients are now on Statins and 109

now on Aspirin (some were taking one or the other

at baseline)

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Case 1

The patient is a 67y/o man retired from the insurance industry and a former body builder. He takes a blood pressure medication, aspirin, and vitamin supplements. BP is well controlled, total cholesterol is195 mg/dl and HDL cholesterol is 44 mg/dl. His ASCVD risk score was 19.3%. After reviewing these findings he agreed to continue his Lisinopril 5 mg and his 81mg aspirin but also agreed to start pravastatin 20 mg each evening for primary prevention to reduce this significant risk.

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Case 2

The patient is a 61y/o women with a past medical history of MS and presents for routine f/u for persistent depression following the loss of her spouse 2 yrs ago. She is doing quite well with a slow intentional weight loss program and excellent BP control. She has also retired from her public government position. Her cholesterol measured at 252 mg/dl with an HDL of 72 mg/dl. Her calculated ASCVD risk score was 8.0% and she is a current smoker. She agreed to pursue smoking cessation and to reach her BMI target of 25. For immediate risk reduction we began atorvastatin 10mg to be taken along with Co Q 10 daily. She will continue Lexapro 20 mg as before.

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Heart Health NOWUsing the ASCVD risk score in daily practice

Time effect on my visits?

Reaction and perceptions regarding the approach and impact after engaging over 200 folks?

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Heart Health NOWAdvancing Heart Health in NC Primary Care

Conclusions

- With a system in place (huddles / MA training and participation),

calculating ASCVD risk scores is pretty easy.

- Time commitment before and during the visit is small

- Patients are impressed by the results and engage well in

risk prevention discussions

- It’s fun for the clinic team because interventions related to the risk

score are clearly impactful

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How Impactful Can HHN Interventions Be?

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Some ASCVD Risk Score Facts

The score does not apply to people who already have vascular disease

It’s preferred to Framingham because it includes stroke

Overestimates the risk for highest end of SES and for people of Asian decent

Underestimates the risk for those with inflammatory conditions, e.g Rheumatoid Arthritis, HIV

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Some ASCVD Risk Score Facts

Simply repeating the risk score after treatment does not provide accurate results for new risk status!!!!

Only establishes baseline risk.

So how do patients know how much treatment will help?

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Lloyd-Jones et al. J Am Coll Cardiol. 2017 Mar 28;69(12):1617-1636

Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool

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How Does Each ABCS Intervention Help?

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Hypertension

Achieving blood pressure control – average relative risk reduction of 25%

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Aspirin

Adding an 81mg aspirin leads to a 10% relative risk reduction

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Statins

Statin treatment produces a relative risk reduction of 25%

14% reduction in all-cause mortality

Diet and exercise counseling have independent effects on CVD risk

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Smoking Cessation

Greatest potential benefit but takes time!

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Time Since Tobacco Cessation

ASCVD Relative Risk Reduction

1 year 15%

2 years 25%

3 years 40%

4 years 50%

Other Important Principles

Treatment effects (relative risk reduction) are multiplicative but cannot achieve improvements better than the age-based minimum

The absolute risk reduction is greater when the baseline risk is greater.

(For example, if baseline risk score is 8% then

starting a statin will reduce the risk score by 25% to

6%, a 2% absolute risk reduction. If baseline = 20%

the post-statin risk score becomes 15%, a 5%

absolute risk reduction) 21

Dr. Early’s - Case 1

The patient is a 67y/o man retired from the insurance industry and a former body builder. He takes a blood pressure medication, aspirin, and vitamin supplements. BP is well controlled, total cholesterol is195 mg/dl and HDL cholesterol is 44 mg/dl. His ASCVD risk score was 19.3%. After reviewing these findings he agreed to continue his Lisinopril 5 mg and his 81mg aspirin but also agreed to start pravastatin 20 mg each evening for primary prevention to reduce this significant risk.

Adding pravastatin reduces ASCVD risk score to 15.5%

Having the aspirin on board decreases to 14%

If uncontrolled HTN at baseline, gets controlled then score falls to 11.2%*

22* Nearly halve 10 year mortality risk

Your Turn

H.R. is a 58 y/o white male who is here for a BP check. He has had several readings of 180/104 at the pharmacy. His BP is similar on your exam. His cholesterol is 230 with an HDL of 32. He smokes a pack of cigs per day. Hgb A1c is 5.5. Hates to take medicine!

? Baseline risk score

? How would you address treatment options

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Your Turn

H.R. is a 58 y/o white male who is here for a BP check. He has had several readings of 180/104 at the pharmacy. His BP is similar on your exam. His cholesterol is 230 with an HDL of 32. He smokes a pack of cigs per day. Hgb A1c is 5.5. Hates to take medicine!

? Baseline risk score 32%

? How would you address treatment options

- BP controlled – 24%

- Then statin – 18%

- Add aspirin – 16.2%

- Smoking cessation can drop risk to 8% (4 years) 24

Conclusions

The higher a patient is at risk the more he or she benefits from cardiovascular risk reduction therapies

As Dr. Early described, just showing a patient his / her 10 year risk of heart attack, stroke, or death can motivate acceptance of new medical therapy

Adding the potential benefit and sharing in a step wise manner, may motivate at risk patients even further.

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