Online-Only Appendix
Appendix 1: Additional Smartphone Screenshots of the 2013 ACC/AHA Guidelines
ASCVD Risk Estimator App. Panel (A) shows the risk estimator tab, (B) the clinicians tab, and
(C) the patients tab.
(A)
(B)
(C)
Appendix 2: Clinician-Patient Risk Discussion Case Examples
We believe that discussion of case examples may help communicate and reinforce the
principles discussed in this review. In choosing these two specific cases, it is a recognized
limitation that we cannot comprehensively address all of the principles within the paper or all of
the types of scenarios that will be encountered in practice. Nevertheless, applying the principles
of the risk discussion to case scenarios is a useful exercise that forces precision in discussion and
brings the principles closer to reality.
Case 1
Consider a 62-year-old African-American woman who presents for risk factor
management. She has a history of obesity, osteoarthritis, hypertension, atrial fibrillation, and
dyslipidemia. She is a lifelong non-smoker, sedentary, and follows a predominantly vegetarian
diet. Her mother suffered a stroke at 64 years of age, followed by a prolonged recovery.
The patient’s active medications include lisinopril 20 mg daily, metoprolol succinate 50
mg daily, Tylenol arthritis as needed, and warfarin at a dose of 5 mg per day except on Tuesdays
and Saturdays, when she takes 2.5 mg. Her latest international normalized ratio (INR) is 3.3,
which has been difficult to maintain in her target range of 2 to 3.
On physical examination, the patient’s body mass index is 31 kg/m2. Her blood pressure
is 128/70 mm Hg (similar to home readings). Physical examination is remarkable for acanthosis
nigricans. The clinician has the patient do squats with her arms stretched out forward. She is able
to perform these with good balance and without significant discomfort in her muscles or joints.
The fasting lipid profile shows a total cholesterol of 206 mg/dl, HDL-C of 43 mg/dl,
triglycerides of 187 mg/dl, and Friedewald-estimated LDL-C of 126 mg/dl. A comprehensive
metabolic panel is normal except for a fasting blood sugar of 118 mg/dl. The HbA1c is 6.1%. A
TSH is normal.
The clinician and patient review risk factors. These include hypertension, which is wellcontrolled on current therapies. Her lipid profile shows that her numbers are not optimal. The
clinician and patient estimate her ASCVD risk on the clinician’s smartphone using the
ACC/AHA Risk Estimator App as 8.7%. It is explained that this means that of 100 people
similar to the patient, about 9 of them would be expected to have a heart attack or stroke over the
next 10 years.
Considering treatable non-lipid risk factors, the clinician discusses the finding of
acanthosis nigricans, explaining that this suggests that the body is not able to process sugar
normally. The clinician notes that the fasting blood sugar of 118 mg/dl and HbA1c of 6.1%
corroborate this. It is mentioned that excess body weight and too little physical activity may
contribute to this.
Building on that point, diet and physical activity habits are reviewed, and a healthy
lifestyle is endorsed. While the patient is a vegetarian, she is obese, and the clinician discusses
the need for smaller portion sizes and greater physical activity to achieve weight loss. Limiting
sodium intake is an important aspect of this patient’s diet as well and she expresses
understanding of this. The clinician advises the patient to review the lifestyle recommendations
provided in the patient tab of the ASCVD Risk Estimator App after the encounter on her
smartphone or home computer. In addition, the clinician offers a dietitian referral to which the
patient is agreeable. The clinician advises that the guideline recommendation is at least 14
dietitian sessions over 6 months, while acknowledging that the patient can work with the
dietitian to arrange a practical schedule of sessions. The physician emphasizes the value of even
moderate weight loss in reducing many of the cardiometabolic risk factors.
Based on clinical experience and supportive literature, the clinician recommends that the
patient begin using a pedometer with a general goal of 10,000 steps/day and plan to establish a
personal step goal at follow-up based on the initial results. The patient notes that her
osteoarthritis of the knees may limit her progress, but expresses a willingness to try her best. The
clinician also discusses the option of seeing a nutritionist for detailed dietary counseling and the
patient agrees that she would like to pursue that option.
The clinician goes on to discuss the potential for risk reduction from lipid-lowering
therapy based on her lipid profile and absolute risk estimate. The clinician notes that the 2013
ACC/AHA cholesterol guidelines advise that the patient is in a statin benefit group based on her
absolute ASCVD risk level of ≥7.5% and, therefore, a moderate-to-high intensity statin may be
appropriate. It is discussed that lifestyle changes are key, but that on top of that, a statin may
reduce her risk of heart attacks and strokes. It is noted that statins, like any therapy, have the
potential to cause adverse effects, but the cardiovascular benefits substantially outweigh major
irreversible harms.
The clinician offers the patient the chance to express her feelings or ask any questions
about the information discussed thus far, particularly the treatment options. The patient conveys
that, based on her risk, she is certain that she wants start working harder to improve her lifestyle
habits and also wants to start a statin right now. The clinician notes that one option is to monitor
her progress with intensive lifestyle change before committing to statin therapy. However, she
says that she wants to do everything possible to avoid the same fate of her mother and therefore
prefers to start the statin in combination with lifestyle change. The clinician provides a nutrition
referral, reminder to begin using a pedometer and log results, and prescribes a statin. Especially
given the presence of obesity and metabolic syndrome, the clinician reemphasizes the critical
importance of lifestyle changes.
In choosing the statin, the clinician recognizes that rosuvastatin and simvastatin have
potential interactions with her warfarin and that her INR has already been difficult to control.
Atorvastatin 10 mg was suggested as a moderate intensity statin option. The clinician explained
that statins can raise blood sugar and she could progress more rapidly to a diagnosis of diabetes
but this acceleration is less likely with a moderate than a high intensity statin and it usually is
measured in weeks not years. The clinician noted that if she did not improve lifestyle through
regular physical activity, an improved diet, and achieve modest weight loss, then progression to
diabetes was more likely to occur. On the other hand, the clinician explained that if she
progressed to diabetes, she would benefit even more from statin therapy as those at highest risk
have a higher absolute benefit. They arrange follow-up to assess progress with lifestyle changes,
statin tolerance and adherence, and reassess her lipid profile.
Case 2
Let us consider a 73-year-old Chinese-American man who presents for risk factor
management. He has a history of benign prostatic hypertrophy, but no other medical problems.
He is currently a non-smoker, although he has smoked on and off during his life. He reports
walking a lot and follows a Chinese diet. He denies a family history of cardiovascular disease.
The patient’s active medications include tamsulosin 0.4 mg daily.
Physical examination is unremarkable. His body mass index is 26 kg/m2. His blood
pressure is 138/72 mm Hg. The lipid profile shows a total cholesterol of 186 mg/dl, HDL-C of
62 mg/dl, triglycerides of 75 mg/dl, and Friedewald-estimated LDL-C of 109 mg/dl.
The clinician and patient make note that the patient does not have traditional risk factors
at this time. Using the ACC/AHA ASCVD Risk Estimator App, his 10 year ASCVD risk is
estimated at 9.4%. The clinician notes to the patient that this is high mainly because of his age.
The clinician and patient also see the note in the app that this estimate may represent an
overestimate of risk in persons of East Asian ancestry. The clinician also points out that the risk
estimate does not take into account his prior smoking.
The clinician reinforces the importance of continued abstinence from smoking. The
patient and clinician review his diet and physical activity habits in more detail, and identify
consumption of more vegetables as an area for focus. The clinician advises the patient to review
the lifestyle recommendations provided in the patient tab of the ASCVD Risk Estimator App
after the encounter on her smartphone or home computer.
The clinician goes on to discuss the potential for risk reduction from lipid-lowering
therapy based on his lipid profile and absolute risk estimate. The clinician notes that the 2013
ACC/AHA cholesterol guidelines advise that the patient is in a statin benefit group based on his
absolute ASCVD risk level of ≥7.5% and, therefore, a moderate-to-high intensity statin is
appropriate. The patient is surprised by this since his cholesterol numbers are okay and he does
not have any risk factors. He is hesitant to start a statin. He had read that statins cause memory
loss and other bad effects.
The clinician acknowledges the patient’s concerns and uncertainty about starting a statin.
He clarifies that memory loss has rarely been reported in patients taking statins, but that the
evidence for a causal connection is not clear. The clinician notes that the highest quality
scientific studies do not show memory loss.
The patient conveys that the possibility that the risk estimator may overestimate risk in
people of East Asian ancestry is adding to his uncertainty. The clinician validates this important
point and mentions that other testing options are available to help increase the certainty of the
risk estimate. The clinician mentions that the guidelines identify a coronary artery calcium
(CAC) scan as being most helpful. The clinician notes that this is commonly known as a “heart
scan” and looks for hardening of the arteries. It does require radiation, but the amount is very
low, and similar to a bilateral mammogram. There is the possibility of finding lung nodules that
require follow-up about 5% of the time.
Ultimately, the patient decides that he would like to have the additional information from
the CAC scan. His insurance covers the cost of the test based on the latest guidelines. They
schedule the CAC test and arrange for a follow-up appointment. The result of the CAC scan is
zero, the best possible result. The guidelines indicate that a score above 300 or >75th percentile
for age/sex/ethnicity would have been considered high and would have meant that statin therapy
should be even more strongly considered. However, because the score is zero, the patient and
clinician decide not to start a statin, and to focus on continued abstinence from smoking and a
heart healthy lifestyle for now.
For additional case discussions, please see:

Dyslipidemia: A CardioSource Clinical Community. Case Challenges Archive.
Available at: http://ldl.cardiosource.org/Case-Challeges/Archive.aspx. Accessed October
26th, 2014.

Cardiometabolic Disease: A CardioSource Clinical Community. Case Challenges
Archive. Available at: http://cardiometabolic.cardiosource.org/CaseChallenges/Archive.aspx. Accessed October 26th, 2014.

Martin SS, Stone NJ, Blumenthal RS. The risk discussion: A key virtue of the 2013
ACC/AHA cholesterol treatment guidelines. Cardiology Today. Available at:
http://www.healio.com/cardiology/guidelines/news/online/%7Bb672ff07-1288-4fee9407-82cb3821a8c9%7D/the-risk-discussion-a-key-virtue-of-the-2013-accahacholesterol-treatment-guidelines. Accessed October 26th, 2014.

Lindley E, Lloyd-Jones DM, Goff DC. Co-Chairs of CVD risk guidelines discuss a
difficult case. CardioExchange. Available at:
http://www.cardioexchange.org/voices/guideline-co-chairs-discuss-a-difficult-patient/.
Accessed October 26th, 2014.