Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology

Abstract

The Million Hearts Initiative has a goal of preventing 1 million heart attacks and strokes-the leading causes of mortality-through several public health and healthcare strategies by 2017. The American Heart Association and American College of Cardiology support the program. The Cardiovascular Risk Reduction Model was developed by Million Hearts and the Center for Medicare & Medicaid Services as a strategy to assess a value-based payment approach toward reduction in 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD) by implementing cardiovascular preventive strategies to manage the "ABCS" (aspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation). The purpose of this special report is to describe the development and intended use of the Million Hearts Longitudinal ASCVD Risk Assessment Tool. The Million Hearts Tool reinforces and builds on the "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" by allowing clinicians to estimate baseline and updated 10-year ASCVD risk estimates for primary prevention patients adhering to the appropriate ABCS over time, alone or in combination. The tool provides updated risk estimates based on evidence from high-quality systematic reviews and meta-analyses of the ABCS therapies. This novel approach to personalized estimation of benefits from risk-reducing therapies in primary prevention may help target therapies to those in whom they will provide the greatest benefit, and serves as the basis for a Center for Medicare & Medicaid Services program designed to evaluate the Million Hearts Cardiovascular Risk Reduction Model.

Keywords: AHA Scientific Statements; cardiovascular diseases; morbidity; mortality; myocardial infarction; population; prevention; stroke.

Figure 1

Patient Scenario

Figure 2

Data entry for estimation of 10-year risk for ASCVD at a baseline visit, for the example provided in the patient scenario (Figure 1) AA indicates African American, or black; ASCVD, atherosclerotic cardiovascular disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; and WH, non-Hispanic white.

Figure 3

Baseline 10-year ASCVD risk estimate for the patient scenario, and projected ASCVD risk if a given therapy or combination of therapies is used ASCVD indicates atherosclerotic cardiovascular disease; and BP, blood pressure.

Figure 4

Suggested clinical algorithm for prioritizing decisions regarding preventive therapies in the Million Hearts Cardiovascular Risk Reduction Model *Patients with clinical atherosclerotic cardiovascular disease or LDL-C 190 mg/dL should be treated with high-intensity (or maximally tolerated) statin. ^†Use USPSTF recommendations and consider the potential risk for major bleeding when considering use of aspirin. ACE-I indicates angiotensin-converting-enzyme inhibitor; ASA, aspirin; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; LDL-C, low-density lipoprotein–cholesterol; MD, physician; and SBP, systolic blood pressure.

Figure 5

Data entry for estimation of updated 10-year risk for ASCVD at a follow-up visit, for the example provided in the patient scenario (Figure 1). AA indicates African American, or black; ASCVD, atherosclerotic cardiovascular disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; and WH, non-Hispanic white.

Figure 6

Ten-year ASCVD risk values for use at a follow-up visit: 10-year ASCVD risk estimate at baseline visit for the patient scenario in Figure 1, 10-year ASCVD risk at follow-up if nothing had been done in the interim, and updated 10-year ASCVD risk based on patient’s current age, baseline risk, and achieved risk factor values at follow-up visit. ASCVD indicates atherosclerotic cardiovascular disease.

Figure 7

Data entry for estimation of future 10-year risk for ASCVD after a follow-up visit if a statin was started, with reduction of LDL-cholesterol to 100 mg/dL, for the example provided in the patient scenario in Figure 1 AA indicates African American, or black; ASCVD, atherosclerotic cardiovascular disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; and WH, non-Hispanic white.

Figure 8

Ten-year ASCVD risk values for use at a follow-up visit: 10-year ASCVD risk estimate at baseline visit for the patient scenario in Figure 1, 10-year ASCVD risk at follow-up if nothing had been done in the interim, and updated 10-year ASCVD risk based on patient’s current age, baseline risk, and future projected risk factor values after initiation of a statin and continuation of current therapies. ASCVD indicates atherosclerotic cardiovascular disease.