The CV Primary Prevention Choice tool will be integrated within electronic medical record systems and implemented in primary care settings. An NIH-funded hybrid implementation trial is underway led by Dr. Jennifer Ridgeway.
CV Prevention Choice (link to the online tool)
Details about the calculator assumptions
We use best estimates of risk reduction against this risk estimation to propose a revised ASCVD risk given the interventions chosen, assuming independence. For further detail on how to calculate the current risk using the ASCVD risk calculator, please refer to pages 32-34 on the 2013 Report on the Assessment of Cardiovascular Risk: Full Work Group Report Supplement. [8] For each intervention, we used their RR estimates to calculate the future risk of having a coronary event in the next 10 years if the patient started, or stopped using, that intervention. The future risk is calculated by multiplying the current risk by the RR overall. The RR overall is calculated using the RR estimates shown in the following table, which are different depending on the use status of the intervention (i.e., if a medicine and/or an activity is started or stopped). A patient’s RR overall is calculated by multiplying together the RRs of each intervention that the patient chooses to start using, and then further multiplying by the RRs of each intervention that the patient is currently using that they and their clinician elect to stop using. The RR of an intervention that is stopped is the inverse of the RR of an intervention that is started
RR overall = RR interventions started * RR interventions stopped
This means for example, that if a patient switches from medium to high dose statins, then:
RR overall = RRstatins high * 1/RRstatins medium
Why is multiplying all risk reduction estimates acceptable? To our knowledge, there is no evidence on how to quantify the effect of when a medicine is stopped. Therefore, we used a mathematical approximation of how to quantify this. Experts in cardiology considered it an adequate approach to try to estimate risk reduction and agreed that the modification of risk was agreeable.
Any interventions that the patient is currently using and will continue to use are not included in the calculation of RR overall and therefore do not contribute to the estimate of future risk. This reflects the difficulty of determining any further risk reduction that may be achieved by continuing current interventions beyond that which is reflected in the patient’s current risk estimate. (For example, for a patient currently taking a blood pressure lowering medicine, the benefits of the intervention are reflected in the estimate of the patient’s current risk and it is unknown to what extent continued use of the medication will lower that risk further.)
Published protocol
Video demonstration
LEGACY TOOLS
(No longer necessarily up-to-date)
Statin/Aspirin Choice Decision Aid
The risk reductions attributed to statins and decision aids come from systematic reviews of randomized trials of primary prevention of coronary events with statins (25-30% reduction in risk of coronary events) and aspirin (15-20% reduction in coronary events).
The risk reduction in coronary events with fixed standard dose statins (atorvastatin 10 mg, simvastatin 40 mg, pravastatin 40 mg, rosuvastatin 5 mg) has been stable for years and was recently documented in a systematic review to be 25%, with high dose statins (2-3 times standard dose) adding about 15% relative risk reduction (i.e., 40% risk reduction).
Low-dose aspirin can reduce coronary events by about 20-25% and can impact the risk and outcomes of colon cancer and other cancers.
Tools:
Risk calculators:
- Framingham: 10-year Coronary Heart Disease Risk – Wilson et al (1998)
- DAgostino 1994: Formula for stroke risk
- Reynolds Risk Score
- ACC/AHA Pooled Cohort Calculator
Decision aids to be used during the encounter:
- Statin Choice tool
Key Assumptions:
- The risk reductions attributed to statins and decision aids come from systematic reviews of randomized trials of primary prevention of coronary events with statins (25-30% reduction in risk of coronary events) and aspirin (15-20% reduction in coronary events).
- The risk reduction in coronary events with fixed standard dose statins (atorvastatin 10 mg, simvastatin 40 mg, pravastatin 40 mg, rosuvastatin 5 mg) has been stable for years and was recently documented in a systematic review to be 25%, with high dose statins (2-3 times standard dose) adding about 15% relative risk reduction (i.e., 40% risk reduction).
Decision aids in practice:
Additional resources:
Statin/Aspirin Choice
Decision aids used in a 98-patient randomized trial (specialty care and independently by another group in a primary care clinic in New York) publications:
- Nannenga MR, Montori VM, Weymiller AJ, et al. A treatment decision aid may increase patient trust in the diabetes specialist. The Statin Choice randomized trial. Health Expect 2009;12:38-44.
- Jones LA, Weymiller AJ, Shah, N. Should clinicians deliver decision aids? Further exploration of the Statin Choice randomized trial results. Med Decis Making 2009;29:468-474.
- Weymiller AJ, Montori VM, Jones LA, et al. Helping patients with type 2 diabetes mellitus make treatment decisions: Statin Choice randomized trial. Arch Intern Med 2007;167:1076-1082.
- Montori VM, Breslin M, Maleska M, Weymiller AJ. Creating a conversation: Insights from the development of a decision aid.PLoS Med 2007;4(8):233.
- Mann DM, Ponieman D, Montori VM, Arciniega J, McGinn T. The Statin Choice decision aid in primary care: a randomized trial. Patient Educ Couns 2010; 80: 138-140.
NIH-funded Decision Aids in Diabetes (DAD) trial publications:
- Ruud KL, Leblanc A, Mullan RJ, Pencille LJ, Tiedje K, Branda ME, Van Houten HK, Heim SR, Kurland M, Shah ND, Yawn BP, Montori VM. Lessons learned from the conduct of a multisite cluster randomized practical trial of decision aids in rural and suburban primary care practices. Trials. 2013 Aug 21;14(1):267.
- Branda ME, LeBlanc A, Shah ND, Tiedje K, Ruud K, Van Houten H, Pencille L, Kurland M, Yawn B, Montori VM.Shared decision making for patients with type 2 diabetes: a randomized trial in primary care. BMC Health Serv Res. 2013 Aug 8;13:301. doi: 10.1186/1472-6963-13-301.
- Tiedje K, Shippee ND, Johnson AM, Flynn PM, Finnie DM, Liesinger JT, May CR, Olson ME, Ridgeway JL, Shah ND, Yawn BP, Montori VM. ‘They leave at least believing they had a part in the discussion’: Understanding decision aid use and patient-clinician decision-making through qualitative research. Patient Educ Couns. 2013 Apr 15. doi:pii: S0738-3991(13)00122-5. 10.1016/j.pec.2013.03.013.
- LeBlanc A, Ruud KL, Branda ME, Tiedje K, Boehmer KR, Pencille LJ, Van Houten H, Matthews M, Shah ND, May CR, Yawn BP, Montori VM. The impact of decision aids to enhance shared decision making for diabetes (the DAD study): protocol of a cluster randomized trial. BMC Health Serv Res. 2012 May 28;12:130. doi: 10.1186/1472-6963-12-130.
Aspirin Choice
- Kent DM, Shah ND. Personalizing evidence-based primary prevention with aspirin: Individualized risks and patient preferences. Circ Cardiovasc Qual Outcomes 2011;4:260-262.
DISCLAIMER: No decision aid replaces the conversation patients should have with their clinicians to make important, clinical decisions. Use of these decision aids carries no liability to its developers or to the Mayo Clinic Foundation for Education and Research.
Feedback
If you download our decision aids, we would love to hear from you! Please send us a note at kerunit@mayo.edu to let us know who you are, why you are interested in the decision aid(s), and how you plan to use them. Remember to check back to this page periodically to make sure you are using the most up-to-date version(s).