Online Appendix for the following September 29, 2009 JACC article TITLE: Value and Limitations of Existing Scores for the Assessment of Cardiovascular Risk: A Review for Clinicians AUTHORS: Marie Therese Cooney, MB, Alexandra L. Dudina, MB, Ian M. Graham APPENDIX Online Table 1: Studies assessing the impact of risk estimation systems availability on risk factor control First Author Pub Year Study Name Physicians and Patients included Design of study – Intervention Risk estimation system used Outcome measure & duration of follow-up Results Other Details Hanon(1) 2000 953 general physicians 1,243 hypertensive (BP >140/90) patients aged 18-74 years WHO/ISH risk charts – based on Framingham Control of BP after 8 weeks of follow-up No difference in BP control between those with known Framingham risk and those without Correlation between estimated and calculated risk was poor – 35% Hetlevik(2) 879 patients in Randomised to Framingham risk displayed in chart / usual care. All patients were subject to the same treatment protocol Fosinopril 20mg OD +/hydrochlorothiazide after 4 weeks Each health centre was Norwegian risk Differences in DBP difference in favor of intervention group 2000 intervention group & 1,119 control group randomised to receive the computerized system and training or not score – relative risk compared to 40 year old woman Hall(3) 2003 323 Patients with diabetes without CVD or renal disease, aged 35-75 years 614 patients aged between 60 and 79 years with a diagnosis of hypertension Patients randomised to clear display of New Zealand 5 year risk score in notes versus usual care New Zealand 5 year risk score Randomised to: Computerized based clinical decision system & risk chart Risk chart Usual care New Zealand 5 year risk score Lowensteyn(5) 1998 CHAS Study 253 community based physicians and 958 patients aged 30-74 years, free of CVD Patients were randomised to receive a full cardiovascular profile within 10 days of assessment or to receive this information only if they returned for followup visit in 3 months. Computer generated risk profile including total CVD risk (Modified Framingham) and CV risk age Grover(6) 2007 CHECK-UP Study 230 primary care physicians 2687 patients (High risk individuals with lipid levels above target) Patients randomised to receive a one page CV risk profile The risk profiles were updated at the second (3 month) visit in order to demonstrate changes due to therapy and lifestyle change. Framingham & LRPC CV life expectancy model Risk age Montgomery (4) 2000 SBP, DBP, TC, BMI, risk score for MI. Followup for 18 months Alterations in prescribing – diabetes, BP, lipid treatment & referral to dietician % in each group with 5 year risk > 10%, SBP , DBP, CV drug prescription, after 12 months of follow-up Change in coronary risk score & lipid levels after 3 months % returning for follow-up visit in 3 months. Change in lipid levels & coronary risk score & proportion reaching lipid targets after 12 months of follow-up (1mmHg) No difference between the two groups in prescribing overall. The intervention group – more high risk individuals were prescribed BP (20% vs. 8%) and lipid lowering treatment (17% vs. 7%) - without an increase in the prescribing in the low risk group. No difference in absolute risk between the three groups. Chart only group achieved greater reductions in SBP than usual care group 4.6mmHg (-8.4 to -0.8) and more likely to be prescribed 2 CV drugs or 3 CV drugs** Reduction in the numbers attending for follow-up in the intervention group and a higher percentage of these were high risk individuals, than those who returned in the control group. The profile group had greater reductions in TC. LDL. TC/HDL ratio, predicted 8 year coronary risk score. Significantly greater mean reductions in LDL cholesterol & total cholesterol/ HDL cholesterol ratio occurred in intervention group; -3.3mg/dl (-5.4 to -0.1) and -0.1 (-0.2 to -0.1) respectively. The impact of the risk profile was greater in those with worse profiles. Greater reductions in SBP, DBP and coronary risk score were also seen in the intervention group. Suggests better usage of paperbased rather than electronic risk estimation systems* Participation in the program by physicians was poor in both control and intervention groups * Note the computerized system was older and not windows based – system did not allow user access to visual display of risk. ** Also, suggestion that those in the computerized and chart only groups who were at higher baseline risk achieved greater reductions in risk over the follow-up time, compared to the usual care group Online Figure 1: Odds ratios for myocardial infarction in patients older and younger than 60 years from the INTERHEART study, from Anand et al. (7) 1. Hanon O, Franconi G, Mourad JJ, Baleydier A, Croce I, Girerd X. [The estimation of cardiovascular risk in hypertensive patients is not modified by management of the hypertension]. Arch Mal Coeur Vaiss 2000;93:943-7. 2. Hetlevik I, Holmen J, Kruger O. Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system. Scand J Prim Health Care 1999;17:35-40. 3. Hall LM, Jung RT, Leese GP. Controlled trial of effect of documented cardiovascular risk scores on prescribing. BMJ 2003;326:251-2. 4. Montgomery AA, Fahey T, Peters TJ, MacIntosh C, Sharp DJ. Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial. BMJ 2000;320:686-90. 5. Lowensteyn I, Joseph L, Levinton C, Abrahamowicz M, Steinert Y, Grover S. Can computerized risk profiles help patients improve their coronary risk? The results of the Coronary Health Assessment Study (CHAS). Prev Med 1998;27:730-7. 6. Grover SA, Lowensteyn I, Joseph L, et al. Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy: the CHECK-UP study: a randomized controlled trial. Arch Intern Med 2007;167:2296-303. 7. Anand S, Islam S, Rosengren A, et al. Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. Eur Heart J 2008;29:932-940.