Implementation Guide (PDF 569 KB)
This artifact provides the ability to calculate a baseline 10-Year ASCVD risk score to support primary prevention of ASCVD. It utilizes the 2013 ACC/AHA pooled cohort equation to calculate the risk of developing a first time "hard" ASCVD event, defined as: nonfatal myocardial infarction (MI), coronary heart disease (CHD) death, nonfatal stroke, or fatal stroke.
It addresses the first of 3 clinical scenarios where CMS's Million Hearts® Model Longitudinal ASCVD Risk Assessment Tool might be used:
1. Calculation of a baseline 10-Year ASCVD risk assessment score
2. Prospective estimations of ASCVD risk in support of shared decision-making while considering the benefits of therapies, alone or in combination
3. Calculation of updated risk after preventive therapies have been initiated
CDS guidance that facilitates shared decision-making based on prospective risk estimates, along with updated risk calculation after the initiation of therapy will be included in separate CDS artifacts.
Artifact Creation and Usage
This artifact was developed by MITRE software engineers and clinical informaticists, in collaboration with clinical subject matter experts and leaders from the Million Hearts® Model Initiative. That initiative is no longer active, so the Centers for Medicare and Medicaid (CMS) is no longer maintaining and updating the model, therefore the CDS artifact now has a retired status.
Additional information about MITRE's health expertise is available here.
If you would like further information, would like to give us feedback, or have any questions about this artifact, please contact us at ClinicalDecisionSupport@ahrq.hhs.gov.
|This CDS logic is expressed using Clinical Quality Language (CQL) and the FHIR Draft Standard for Trial Use 2 (DSTU2) data model. All value sets referenced in the logic are published on the Value Set Authority Center (VSAC). Additional details about these resources can be accessed via the following URLs:
FHIR DSTU2: https://www.hl7.org/fhir/DSTU2/index.html
Structured code that is interpretable by a computer (includes data elements, value sets, logic)
Provides the ability to calculate and display a patient's baseline 10-Year ASCVD risk score to inform a plan of care
"The 10-year ASCVD Risk Tool is intended for use in a broad population aged 40-79 years and eligible for primary prevention of ASCVD. The baseline 10-year ASCVD risk estimate is calculated using the ACC/AHA 2013 Pooled Cohort Equations (PCE), which provide sex- and race-specific 10-year estimates of ASCVD risk, have been validated in a broadly representative sample of U.S. whites and African-Americans, and are well calibrated for the Medicare population." Source: Final Technical Report: Estimating Benefits in Risk Reduction From Cardiovascular Preventive Therapies in Medicare Patients: Development of the Longitudinal ASCVD Risk Estimator.
This artifact is intended for use by providers while delivering care in an outpatient setting.
Online calculators and the Million Hearts® Model Longitudinal ASCVD Risk Assessment Tool appear to use more precise values than those published in the 2013 Report on the Assessment of Cardiovascular Risk: Full Work Group Report Supplement. The CQL code in this artifact aligns with the precision used in the Million Hearts® Model Longitudinal ASCVD Risk Assessment Tool and online calculators.
ASCVD risk scores calculated by the CQL code in this artifact consistently align with scores calculated by online calculators using identical input data. Discrepancies were identified in the test data included in the 2013 Report on the Assessment of Cardiovascular Risk: Full Work Group Report Supplement (e.g., copy/paste errors and incorrect rounding, which can lead to results that are off by as much as 0.001). Ensure robust integration testing if this artifact is implemented in an EHR and validate scores against more than one source.
Since baseline calculation of 10-year ASCVD risk is not reliant on a patient's Low-Density Lipoprotein (LDL) value, or potential treatment with Statin Therapy or Aspirin Therapy, these concepts are not expressed in this artifact. If implementers choose to track these concepts at a "baseline" level prior to initiating or changing therapy, these concepts can be added to the CQL code at that time.
"At present, the risk equation applies most accurately to non-Hispanic Whites and African Americans. For non-White and non-African American ethnic groups, the equations for Whites of the same sex were used, which may provide overestimation of risk for some groups (e.g., East Asian Americans) and underestimation in others (e.g., South Asian Americans)." Source: 2013 Report on the Assessment of Cardiovascular Risk: Full Work Group Report Supplement
Use of the tool is not indicated for individuals who have ASCVD.
"Patients with end-stage renal disease were not included in the derivation sample for the PCEs; such patients require highly individualized care with respect to use of aspirin and blood-pressure-lowering therapies, and data on use of statin medications in ESRD patients do not indicate overall benefit. For some symptomatic and for advanced heart failure patients, similar considerations and highly individualized decision-making may be necessary. However, recent data reinforce the importance of ASCVD risk-reducing therapies even among patients with heart failure. Use of this tool is not indicated for individuals that have ASCVD. For older (and younger) individuals, guidelines recommend individualized care decisions." Source: Final Technical Report: Estimating Longitudinal Risks and Benefits from Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool.
Risk scores calculated on patients with a history of familial hypercholesterolemia may under-represent the patient's true ASCVD risk. "Patients with LDL-cholesterol of at least 190 mg/dL should be evaluated and considered for statin therapy regardless of age and estimated 10-year ASCVD risk." Source: Final Technical Report: Estimating Benefits in Risk Reduction From Cardiovascular Preventive Therapies in Medicare Patients: Development of the Longitudinal ASCVD Risk Estimator.
In 2018 the ACC/AHA released updated guidelines on cardiovascular risk assessment. Per Arps et al. in New Aspects of the Risk Assessment Guidelines: Practical Highlights, Scientific Evidence and Future Goals, "the basic themes of the 2013 guidelines are largely preserved with an adjusted framework accentuating the value of non-traditional risk factors, enhancing the role for coronary artery calcium (CAC) scoring and introducing low-density lipoprotein cholesterol (LDL-C) thresholds for consideration of intensifying lipid lowering therapy." This ASCVD risk calculator does not incorporate the adjusted framework outlined in this article. Source: Arps, K., Blumenthal, R., Martin, S. (2018) New Aspects of the Risk Assessment Guidelines: Practical Highlights, Scientific Evidence and Future Goals. November 18, 2018. Accessed on August 30, 2020 at: https://www.acc.org/latest-in-cardiology/articles/2018/11/14/07/10/new-aspects-of-the-risk-assessment-guidelines.
DeFelippis AP, Young R. (2016) Estimating Longitudinal Risks and Benefits from Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool. Nov 4, 2016. Accessed on Feb 2, 2017 at: http://www.acc.org/latest-in-cardiology/articles/2016/11/04/08/56/estimating-longitudinal-risks-and-benefits-from-cv-preventive-therapies.
Lloyd-Jones DM, Ning H, Huffman MD, Karmali K, Berendsen M, Goff D. (2016) Final Technical Report: Estimating Benefits in Risk Reduction From Cardiovascular Preventive Therapies in Medicare Patients: Development of the Longitudinal ASCVD Risk Estimator.
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB Sr, et al. (2013) 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;00:000–000.
Goff DC Jr, Lloyd-Jones DM, D’Agostino RB Sr, Gibbons R, Greenland P, et al. (2013) 2013 Report on the Assessment of Cardiovascular Risk: Full Work Group Report Supplement. National Heart, Lung, and Blood Institute.
The race- and sex-specific Pooled Cohort Equations* to predict 10-year risk of a first hard ASCVD event should be used in non-Hispanic African Americans and non-Hispanic whites, 40–79 years of age. (ACC/AHA Class of Recommendation I - Procedure/Treatment SHOULD be performed/administered) Source: 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;00:000–000.
Recorded above immediately following the Recommendation Statement.
The recommendation utilizes the ACC/AHA grading system for strength of recommendation is available on page S8 of ACC/AHA 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults accessible at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a
Level of Evidence: AHA/ACC Level B (Limited populations evaluated)
Complete descriptions of the ACC/AHA level of evidence grading system is available on page 2938 of the ACC/AHA Guideline on the Assessment of Cardiovascular Risk.
Decision notes are listed in Appendix A of the attached implementation guide.
Trigger is defined by and created to support local use cases.
|Age >=40 and <=79 years|
|Intervention||DISPLAY segment of the CMS's Million Hearts® Model Longitudinal ASCVD Risk Tool that provides the ability to input the following data concepts:
|Note: The risk score should be calculated whenever possible to facilitate workflow and provider decision making. To this end, if a patient's lab (i.e., Total Cholesterol and HDL Cholesterol) or systolic blood pressure (SBP) results are outside the range specified by the calculator, then the result should be replaced with the nearest value that will be accepted by the tool. For example, the tool allows a SBP value of 90-200 mmHg. If the most recent patient value is "212", it would be replaced with "200" to enable calculation of the score.|
|Intervention||POPULATE fields in CMS's Million Hearts® Model ASCVD Longitudinal Risk Tool|
|Intervention||CALCULATE risk score|
|Intervention||DISPLAY risk score|
|Intervention||DISPLAY the following ERRORS, when indicated:
|Intervention||DISPLAY the following WARNINGS, when indicated:
|Intervention||DISPLAY link to relevant guidelines related to the tool (e.g., http://www.acc.org/latest-in-cardiology/articles/2016/11/04/08/56/estimating-longitudinal-risks-and-benefits-from-cv-preventive-therapies)|
|Action||DOCUMENT risk score|
This artifact is in a retired status.
This artifact was tested by b.well® Connected Health over an 8-week period from June 2019 - August 2019, along with the following 4 artifacts (also published on the CDS Connect Repository):
b.well offers a platform with personalized health management resources targeted to consumers to help them self-manage the entire healthcare process. AHRQ and MITRE would like to thank b.well for their partnership on the pilot. The collaborative effort provided a valuable opportunity to test the CQL CDS expression and learn from the implementation process and end user experiences. High-level details are outlined below. Detailed information on the pilot implementation can be found in the CDS Connect Pilot Report: Preventive Health CDS Interventions document posted within this artifact.