Case Finding (Who to Screen)
An Evidence-Based Alternative
This is not a Palm application. It will run from the web, or it can be downloaded to your own computer and run from there as a web page.
This calculator focuses on primary prevention of cardiovascular events in people without known
heart disease. Derivation tables come
from guidelines recently published by the Canadian Cardiovascular Society (1) and the U.S. Preventive Services Task
Force (2) for lipids and ASA
respectively. The revised 2009 lipid
tables from the
Source studies are done mainly in
Because the FRS is currently used as a guide to both lipid and ASA recommendations for primary prevention, ASA guidelines are included in this calculator. Decision analysis for ASA is now more complex than simply treating each person with a risk over 10%. The risk of GI hemorrhage must also be taken into account, and this risk is considered in the Preventive Task Force guidelines. The guidelines are firm for men, whose risk is primarily myocardial infarction. They are less firm for women between 55 and 65, whose primary risk is stroke.
Another choice to increase precision in those with 10-19% 10-year risk is the use of hsCRP. In males over age 50 and females over age 60 a hsCRP over 2 has been shown with good evidence to change risk status when LDL is below 3.5 mmol/L. This is also included in the calculator as an option, and the recommendation for this test will be flagged if the patient meets the criteria, and the recommendation would be to treat as high risk with a statin based on the JUPITER trial (7). Patients in the moderate risk category receive a treatment recommendation if LDL if above 3.5 mmol/L. Use of CRP remains optional for this calculator because there is disagreement as to whether outcomes are improved. For a brief discussion of an alternative approach to guidelines, please use the evidence based alternative link.
Currently diabetics are evaluated similarly to non-diabetics
unless a woman is over 50 or a man over 45.
Over these age cutoffs they are considered high risk (>20%). Under this age with one additional risk
factor they are also considered high risk.
The calculator will flag these conditions. Emerging or novel risk factors including the
components of metabolic syndrome and selected criteria identified in the
INTERHEART study are built into the optional decision support calculator. They
are helpful in identifying additional relative risk contributions by metabolic
syndrome or multiple factors not evaluated by
Decision analysis for primary prevention has become more
evidence-based and complex. Use of
tables is still possible, but it is prone to error and consumes a great deal of
time. For decisions which have to be
made several times a day by primary care providers, a more efficient means of
calculation is necessary. Existing older
calculators tend to underestimate risk substantially. Many of them are developed using
Caveat: Strict use of this calculator follows the JUPITER criteria, and will result in statin treatment of up to 62% of adults aged 35-75 (13). While there is evidence for benefit in treatment of patients down to low risk, numbers needed to treat become very high. Given the shaky evidence for hs-CRP as a risk factor and LDL as a target, an alternative and simplified evidence-based strategy is suggested here. Links are supplied for those who wish to research this option further.