RISK CALCULATORS

Assessment of risk in 1y Prevention Pre-test probability of CHD in stable Chest Pain Post-test probability of CHD in stable Chest Pain Initial Risk in ST elevation MI Initial Risk in Unstable Angina or non-ST elevation MI Risk in Acute Coronary Syndrome using ExECG+TnT Risk of Cardiac Surgery "Choice" Priority for CABG

Framingham Risk Score Duke Clinical Risk Score

Duke Treadmill Test Score

TIMI Risk Score in ST elevation MI TIMI Risk Score in UA / NSTEMI Risk in ACS derived from ExECG+TnT
EuroSCORE & Parsonnet

"Choice" Priority for CABG Risk of stroke in AF (?Warfarin)

Risk of Stroke in AF (Warfarin/Aspirin)

To use a Risk Calculator, click on a button

Best viewed in 1024x768 screen resolution or higher Designed by Dr John Bayliss (1999-2002) v11 26/10/2002

West Hertfordshire Cardiology, Hemel Hempstead Hospita

John.Bayliss@whht.nhs.uk

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

Framingham predictions of Risk of CHD Event and Risk of Stroke in Primary Prevention
NOTE: The CHD risk calculation is invalid if patient has CHD or FH. The Stroke risk calculation is invalid if patient has already had a TIA/CVA
(limits are 35-74 for CHD risk, 55-85 for Stroke risk) Age Total Cholesterol (if unknown use Male=1.1, Female=1.4) HDL Cholesterol Systolic BP In Atrial Fibrillation ? On AntiHypertensive Rx ? History of Smoking in past year ? History of Diabetes ? History of CHD,CHF or Peripheral Vascular disease ? (if unknown, try 0=N and 1=Y to see range of risk) ECG LVH ? Home

Calculated 10 year risk of CHD event Average 10 year risk of CHD event at this age "Ideal" 10 year risk of CHD event at this age Relative risk of CHD vs Average risk Relative risk of CHD vs Ideal risk Change in risk of CHD event Calculated 10 year risk of Stroke Average 10 year risk of Stroke at this age Relative risk of Stroke vs Average risk Change in risk of Stroke Calculated 10 year risk of Cardiovascular event Advice from Guidelines Hypercholesterolaemia HDL cholesterol Hypertension Anticoagulation in AF to reduce risk of Stroke Validity of CHD Risk calculation

55 5 1.1 140 0 0 0 0 0 0 Male 11.7% 16% 6% 0.7 1.9 3.9% 6% 0.7 15.5%

35-85 yrs mmol/l mmol/l mmHg 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y

Female 7.6% 12% 4% 0.6 1.9 2.0% 3% 0.7 9.6%

Planned or actual change in risk factors 55 55 5 +0% 5 1.1 +0% 1.1 140 +0% 140 0 0 0 0 0 0 0 0 0 0 0 0 Male Female Male 11.7% 7.6% 11.7% 16% 12% 16% 6% 4% 6% 0.7 0.6 0.7 1.9 1.9 1.9 0% 0% 0% 3.9% 2.0% 3.9% 6% 3% 6% 0.7 0.7 0.7 0% 0% 0% 15.5% 9.6% 15.5%

+0% +0% +0%

Female 7.6% 12% 4% 0.6 1.9 0% 2.0% 3% 0.7 0% 9.6%

Statin treatment for Hypercholesterolaemia should be considered if CHD Risk >15-30% Drug treatment for Hypertension should be considered if [BP >=160/100], OR if [BP >=140/90 AND {CHD Risk >15% OR (target organ damage (eg LVH) or diabetes or CV complications)}] People with an absolute risk of >=15% should be considered for treatment with Aspirin, unless C/I Risk may be about 30% higher in Asians, and may be lower in Southern Mediterranean people Risk of CHD event in Familial Hypercholesterolaemia by ages 50, 60 and 70 in Men is 51%, 85% and 100%, in Women 12%, 57%, 74% "Ideal" CHD risk is obtained with: Total Cholesterol <4.1, HDL=1.2 (Male), 1.4 (Female), SBP<120, Non smoker, no Diabetes and no ECG LVH Risk of thromboembolic stroke in AF is reduced more by Warfarin than Aspirin if Previous TIA/CVA, or >65yrs with additional risk factor(s) (risk then usually >6%, reduced to <5% on Warfarin) References: Anderson KM, Wilson PWF, Odell PM, Kannell WB. An updated Coronary Risk Profile. Circulation 1991;83:356-62 Wolf PA, D'Agostino RB, Belanger AJ, Kannel WB Probability of stroke: a risk profile from the Framingham Study. Stroke 1991;22:312-8 Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998;80 (supplement 2):S1-S29 Wood DA, et al Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of the European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension. Eur Heart J 1998;19:1434-503

Designed by Dr John Bayliss (1999-2002) v11

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

Duke Clinical Score: Prediction of CHD in a patient with chest pain

NOTE: This score is not applicable if patient is known to have CHD

Intro!C2
Home

1 2 3 4 5 6

55 Age (original data derived from ages 30-70) 55 Sex 0 0=M, 1=F 0 Precipitated by exercise 0 0=N, 1=Y Brief duration (2-15min) 0 0=N, 1=Y Relieved promptly by rest or GTN 0 0=N, 1=Y Retrosternal 0 0=N, 1=Y Radiating to jaw, neck or L arm 0 0=N, 1=Y Absence of other cause 0 0=N, 1=Y Chest Pain Categorised as: None/Non-Anginal Probability of significant CHD (ACC/AHA Guidelines): 20%

0 Smoking (within past 5 years) Total Cholesterol Diabetes Previous MI ECG: Q waves ECG: ST changes at rest B Probability of significant CHD (Duke):
(>75% stenosis of at least 1 major coronary artery)

0 5 0 0 0 0 23%

0=N, 1=Y mmol/l 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y

Exercise Test usually not indicated

References: Gibbons RJ et al. ACC/AHA/ACP-ASIM Chronic Stable Angina Guidelines

Set thresholds for ExECG

A B

JACC 1999;33:2092197

Diamond GA, Forester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. NEJM 1979;300:1350-8 Chaitman BR et al Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation 1981;64:36-7 Pryor DB et al (from Duke University) Estimating the likelihood of significant coronary artery disease Am J Med 1983;75:771-80 Training sample n=3627, Validation sample n=1811 Study dataset n=5438 (67% had significant CHD at Angio) Study dataset n=5438 (67% had significant CHD at Angio) Pryor DB et al (from Duke University) Value of the history and physical in identifying patients at increased risk for CAD Ann Int Med 1993;118:81-90 Study dataset n=1030 (168 had angio within 90 days, 109 had significant CHD) (c-index 0.87)
Designed by Dr John Bayliss (1999-2002) v11 West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

Set thresholds for ExECG

as an aid in the clinical diagnosis of coronary-artery disease. NEJM 1979;300:1350-8 gh-risk coronary artery disease in patient subsets (CASS). Circulation 1981;64:36-7 e likelihood of significant coronary artery disease Am J Med 1983;75:771-80

history and physical in identifying patients at increased risk for CAD Ann Int Med 1993;118:81-90

Duke Treadmill Score: Predictions of CHD in a patient with chest pain undergoing ExECG
Home NOTE: This score is not applicable if patient is known to have CHD Exercise Test variables Exercise Time 9.0 min Maximum ST deviation 0.0 mm (always a +ve figure, no matter if +ve or -ve deviation) Angina score during ExECG 0 0:None, 1:Non-Limiting, 2: Exercise Limiting Duke Treadmill Score 9

Probability of Significant CHD Probability of Severe CHD 5yr Mortality Overall risk subcategory

19% 15% 14%

probability of >75% stenosis in at least 1 coronary artery probability of 3 vessel CHD or >75% LMS

Low Risk Angiography usually not indicated

References: Mark DB et al NEJM 1991;325:849-53 and Ann Intern Med 1987;106:793-800 Study dataset n=2842 (ExECG within 6 weeks of Cor Angio) 70% Male, median age 49yr (10-90% centiles 37-60) Training sample n=1422, Validation sample n=1420 Shaw LJ et al Circulation 1998;98:1622-30 Study dataset n=2758 (ExECG within 6 weeks of Cor Angio) 70% Male, median age 49yr, 30% prior MI, 47% typical angina, 61% had significant CHD at Angio Training sample n=2758, Validation sample n=467 ROC for predicting significant CHD = 0.76 for DTS, 0.91 for post-test DTS + Clinical score

Designed by Dr John Bayliss (1999-2002) v11

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

TIMI Risk Score for ST Elevation Acute MI (STEMI)

Patient with ST elevation MI = Chest pain > 30min, symptom onset <6hrs ago, ST elevation, no contraindication to thrombolysis HISTORY Age 50 History of Angina 0 History of Hypertension 0 History of Diabetes 0 EXAMINATION Systolic Blood Pressure < 100 0 Heart Rate > 100 0 Killip Class II-IV * (ie clinical heart failure) 0 Weight < 67 kg (< 150 lb) 0 PRESENTATION Anterior ST Elevation or LBBB 0 Time to treatment > 4 hours 0 Total Risk Score Risk of Death by 30 Days from InTIME II trial : Morrow DA et al Circulation 2000;102:2031-7 see www.timi.tv * Killip Classes II : Bilateral crackles in up to 50% of lung fields, isolated S3 III : Bilateral crackles in all lung fields, acute Mitral Regurgitation IV : Cardiogenic shock - Pulmonary Oedema, Systolic BP <90, poor urine output 0 0.8% Low Risk

Designed by Dr John Bayliss (1999-2002) v11

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

Home

ymptom onset <6hrs ago, ST elevation, no contraindication to thrombolysis

(years) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y)

v11

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

TIMI Risk Score for Acute Coronary Syndrome (UA / NSTEMI)

Patient with Unstable Angina (UA) or non-ST elevation MI (NSTEMI) = ischaemic pain within past 24hrs with ST deviation and/or +ve cardiac marker HISTORY Age (years) Current Smoker History of Hypertension History of Hypercholesterolemia (TC > 5mmol/l) History of Diabetes Family History of Coronary Artery Disease Prior angiographic stenosis >50% Use of aspirin within the last 7 days PRESENTATION Severe anginal symptoms (>= 2 episodes of rest pain in past 24 hours) ST deviation (horizontal ST depression or transient ST elevation >= 1 mm) Elevated cardiac markers (either CKMB or cardiac troponin) Total Risk Score (0-7) Risk of Death/MI by 14 Days Risk of Death/MI/Urgent Revascularization by 14 Days from TIMI 11B trial : Antman et al JAMA 2000;284:835-842 see www.timi.tv

50 0 0 0 0 0 0 0 0 0 0 0 3% 4.7% Low Risk

Designed by Dr John Bayliss (1999-2002) v11

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

Home

(years) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y) (0=N, 1=Y)

ardiology, Hemel Hempstead Hospital, Herts HP2 4AD

Risk of Cardiac Death or MI at 5 months after Unstable Angina / ACS

Exercise ECG ExECG Risk category High Risk Intermediate Risk Low Risk ? Risk of Cardiac Death or MI at 5 months Troponin T >0.2mg/l 0.2-0.06mg/l <0.06mg/l

Result Low maximal workload (Less than Bruce II, <=3min), AND ST depression >= 0.1mV in >= 3 leads EITHER a low maximal workload achieved, OR ST depression >= 0.1mV in >= 3 leads Low maximal workload exceeded, AND without ST depression >= 0.1mV in >= 3 leads Unable to perform exercise ECG

34% 16% 5% 27%

19% 9% 7% 16%

22% 7% 1% 3%

Note: The confidence intervals for the quoted risk of cardiac death or myocardial infarction will be wide and may overlap for many of these categories. Furthermore, the results of Troponins and Exercise ECG tests are continuous rather than categorical variables, and should be interpreted accordingly. Thus these categories should be interpreted as indicating the general degree of cardiac risk, rather than a precise figure. References Lindahl B, Andren B, Ohlsson J, Venge P, Wallentin L and the FRISC Study Group. Risk stratification in unstable coronary artery disease. Additive value of troponin T determinations and predischarge exercise tests. Eur Heart J 1997; 18: 762-70. Guidelines for the management of patients with acute coronary syndromes without persistent ECG ST segment elevation. Heart 2000;85:133-142

Designed by Dr John Bayliss (1999-2002) v11

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

EUROSCORE & Parsonnet Logistic risk assessments of cardiac surgery

E,P Age E,P Sex CLINICAL RISKS P Smoker P Hypercholesterolaemia P Hypertension P Diabetes P Obesity P Family History of CHD CLINICAL FEATURES & COMORBIDITY P Aortic Valve Disease P Mitral Valve Disease E LV Ejection Fraction E Serum creatinine > 200 mol/ L E C.O.P.D. E Systolic PAP > 60 mmHg E Unstable angina E Recent myocardial infarction (< 90 days) P LV Aneurysm P Preop IABP E Active endocarditis E Neurological dysfunction E Extracardiac arteriopathy E,P Previous cardiac surgery E,P Critical preoperative state TYPE OF SURGERY E Emergency (within 24hrs) E,P Other than isolated C.A.B.G. E Surgery on thoracic aorta E Postinfarct. septal rupture EUROSCORE predicted mortality (logistic) Parsonnet predicted 30 day mortality 50 yrs 0 0=M, 1=F 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.8% 0.9%
0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 2:<30%, 1:30-49%, 0:>=50% 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y 0=N, 1=Y

Nashef SAM et al. European system for cardiac operative risk evaluation (EuroSCORE). European Journal of Cardio-thoracic Surgery 1999;16:9-13 Parsonnet V et al. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation. 1989;79:I 3-12 See also the Euroscore website

Designed by Dr John Bayliss (1999-2002) v11

West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD

EUROSCORE Definitions
COPD : longterm use of bronchodilators or steroids for lung disease. Extracardiac arteriopathy : any one or more of the following : claudication, carotid occlusion or > 50% stenosis, previous or planned intervention on the abdominal aorta, limb arteries or carotids. Neurological dysfunction : disease severely affecting ambulation or day-to-day functioning. Previous cardiac surgery : requiring opening of the pericardium. Active endocarditis : patient still under antibiotic treatment for endocarditis at the time of surgery. Critical preoperative state : any one or more of the following : ventricular tachycardia or fibrillation or aborted sudden death, preoperative cardiac massage, preoperative ventilation before arrival in the anaesthetic room, preoperative inotropic support, intraaortic balloon counterpulsation or preoperative acute renal failure (anuria or oliguria , 10 mL/h). Unstable angina : rest angina requiring IV nitrates until arrival in the anaesthetic room. Emergency : carried out on referral before the beginning of the next working day. Surgery on thoracic aorta : for disorder of ascending, arch, or descending aorta. Other than isolated C.A.B.G. : major cardiac procedure other than or in addition to C.A.B.G. Developmental dataset n=13,302 Validation dataset n=1,479 (ROC=0.76)

Patient Choice Initiative Priority Score for Coronary Surgery

Select one value from each drop-down list, to calculate priority score and indicate suitability ANGINA OR MEASUREMENT OF ISCHAEMIA SYMPTOM STABILITY 0 LV FUNCTION 0 CORONARY ANATOMY Total Score Should be suitable for choice 0 0 Score 0

Cardiologists should fill in a scoring system to identify patient suitability for the choice initiative at the time of referral to surgeon
The scoring system is a guide and an aid to decision making and the judgement of clinicians will be paramount. Score less than 20 : Patient should be suitable for choice and should be informed at the time they see their cardiologist. Score between 20 30 : Patient will probably also be suitable for choice Score more than 30 : Patients suitability for choice less easily determined by scoring system. Clinician will need to make a judgement on an individual patient basis.
Extending Choice for patients: Information & Advice on establishing the Heart Surgery Scheme DoH 2002 www.doh.gov.uk/extendingchoice/index.htm

Designed by Dr John Bayliss (1999-2002) v11

West Hertfordshire Cardiology, Hemel Hempstead

Selecting patients in AF who benefit most from anticoagulation with Warfarin CHADS2 SIGN Warfarin (target INR 2.5, range 2.0-3.0) reduces relative stroke risk by 68%, Aspirin (75-300 mg/day) reduces relative stroke risk by 20%, compared to placebo. Warfarin increases annual absolute risk of major haemorrhage by 2%, so Only patients at high initial risk of stroke (>6% absolute annual risk) are likely to achieve greater benefit from Warfarin than from Aspirin
see ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation JACC 2001;38:1266i-lxx and European Heart Journal 2001;22: 18521923 (www.acc.org/clinical/statements.htm)

CHADS2 Risk Score

(JAMA 2001,285:2864-2870) (Y=1, N=0) (Y=1, N=0) (Y=1, N=0) (Y=1, N=0) (Y=2, N=0) (0 - 6)
Risk Score 0 1 2 3 4 5 6 Stroke Risk % 1.9 2.8 4.0 5.9 8.5 12.5 18.2

Risk Points Congestive Heart Failure (past or present) 0 Hypertension (past or present) 0 Age >=75 0 Diabetes 0 Stroke or TIA (in past) 0 Risk Score 0 Annual risk of Stroke (rate per 100 pt-years) 1.9 Warfarin NOT indicated

SIGN - Antithrombotic Therapy Guidelines SIGN 1999 (No 36)

Table 1 Group Very High Risk High Risk Mod Risk Low Risk BUT Previous TIA/Stroke >65 + Risk Factor(s)* >65 + No Risk Factor(s)* <65 + Risk Factor(s)* <65 + No Risk Factors* Annual risk of major bleed Annual Risk of Stroke in non-valvular AF UnRx Aspirin Warfarin 12% 10% 5% 5-8% 4-6% 2-3% 3-5% 1-2% 0.1% 2-4% 1% 1% 1-2% 0.5% 2% NNT 18 42 71 142 NNH=100 * Risk factors for thromboembolic stroke - Previous TIA/Stroke - >65yrs - Hypertension - Diabetes - Heart Failure - Echo LV dysfunction - Echo MV calcification - (Echo LA>5cm) - not very predictive

NNT=Number needed to treat with Warfarin instead of Aspirin for 1 year to prevent 1 stroke NNH=Number needed to harm by treating with Warfarin instead of Aspirin for 1 year (causing a major haemorrhage)

So, combining "benefit" and "harm": Overall Annual Risk of Stroke+Major bleed Group UnRx Aspirin Warfarin Very High Risk Previous TIA/Stroke 12% 11% 7% High Risk >65 + Risk Factor(s)* 5-8% 5-7% 4-5% >65 + No Risk Factor(s)* Mod Risk 3-5% 3-5% 3-4% <65 + Risk Factor(s)* Low Risk <65 + No Risk Factors* 1-2% 2% 2.5% An alternative way to express risk to patient when discussing whether to anticoagulate: Annual Risk of NOT having a Stroke in non-valvular AF (Inverse of Table 1) Group UnRx Aspirin Warfarin Very High Risk Previous TIA/Stroke 88% 90% 95% High Risk >65 + Risk Factor(s)* 92% 94% 97% >65 + No Risk Factor(s)* Mod Risk 95% 96% 98% <65 + Risk Factor(s)* Low Risk <65 + No Risk Factors* 98% 99% 99.5% SIGN recommendations (with grade of evidence)
- Patients with AF but without additional Risk factors require no antithrombotic prophylaxis unless there are other indications for aspirin.(A) - Patients with one or more risk factors should be considered for warfarin therapy in preference to aspirin.(A) - Warfarin prophylaxis should also be considered in patients with atrial fibrillation and heart valve disease or prostheses, thyrotoxicosis, intracardiac thrombus, or non-cerebral thromboembolism. (C) - The decision to use warfarin or not should be based on discussion of the balance of risk and benefit with each individual, including assessment of compliance.(B) - To minimise the risk of intracranial bleeding in patients on warfarin, hypertension should be controlled, compliance assessed, and the risks and benefits of warfarin reviewed annually, especially in those aged over 75 years.(Good Practice) - Cardioversion to restore sinus rhythm should be considered in selected patients, because it may avoid the need for long term warfarin.(C)

Other Evidence-based Notes

- Adding Dipyridamole (Persantin) 200mg bd to Aspirin does not reduce the risk of recurrent TIA/Stroke (BMJ 2002;324:71-86). Consider Warfarin instead - Patients allergic to Aspirin should receive Clopidogrel 75mg od instead - If previous history of GI bleed, peptic ulcer or GORD, use PPI (rather than H2 antagonist) with Aspirin or Clopidogrel - Echocardiography is NOT helpful in diagnosing cause of TIA/Stroke in the absence of clinical evidence of cardiac pathology and risk factors - Echocardiography is NOT helpful in deciding need for anticoagulation after TIA/Stroke if patient is in AF: Warfarin is indicated!
Designed by Dr John Bayliss (1999-2002) v11 West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD