ASCVD Risk Estimator Plus is an update to the American College of Cardiology ASCVD Risk Estimator that uses recent science and user feedback to help a clinician and patient build a customized risk lowering plan by estimating and monitoring change in 10 year ASCVD risk.

Use the app to:

• Estimate a patient's initial 10-year ASCVD risk using the pooled cohort equation
• Receive an individualized, risk-based, intervention approach
• Project the impact of specific interventions on a patient's risk
• Guide clinician-patient discussion around customizing an intervention plan
• Update risk at follow-up based on a patient's response to therapy using the Million Hearts Longitudinal model

Advice from the app is derived from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, the 2018 ACC/AHA et.al Guideline on the Management of Blood Cholesterol, the 2017 ACC/AHA et.al Guideline on High Blood Pressure in Adults, the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk, and the 2016 Million Hearts Longitudinal ASCVD Risk Assessment Tool user guide. The information and recommendations in this app are meant to support clinical decision making. They are not meant to represent the only or best course of care, or replace clinical judgment. Therapeutic options should be determined after discussion between the patient and their care provider.

ASCVD Risk Estimator Plus is a starting point for estimating a patient's 10-year risk of developing atherosclerotic cardiovascular disease, and facilitating a discussion with your patient about lowering this risk. The components of the app can be used in the following ways:

"Estimate Risk" Screen: Estimate the patient's 10 year risk for atherosclerotic cardiovascular disease

• At an Initial Visit: Enter patient parameters to estimate their 10-year ASCVD risk at the time of their initial visit with a particular clinician. Use this risk to begin a risk lowering discussion, and to establish a baseline risk for reference and comparison at follow-up visits.
• At a Follow-Up Visit: Enter the patient parameters from the initial visit and the follow-up visit to determine an updated 10-year ASCVD risk based on the patient's achieved change in key risk factors.

"Therapy Impact" Screen: Form a risk-lowering intervention plan with your patient

• "Review Therapy Advice": Review evidence-based suggestions on an intervention strategy to help discuss a risk-lowering treatment plan with your patient.
• "Project Risk Reduction by Therapy": Enter different therapy combinations to view the projected impact those therapies might have on a patient's ASCVD risk.

"Advice" Screen: Summarize and visualize risk

• "Estimated 10-Year ASCVD Risk Profile": Visualize the change in risk over time, the projected risk of different treatment scenarios, and the optimal risk for your patient in one summary graphic.
• "Treatment Advice Summary": Review an expanded version of the evidence-based advice provided on the Therapy Impact screen, including treatment safety information and supporting guideline recommendations.
• "Inputs": Capture a summary of the patient parameters entered into the app.
• "Email": Email from your device a summary of the calculated ASCVD risk, treatment suggestions, and patient input to use as a patient handout or to include in your records for this patient.

The information and recommendations in the app are meant to support clinical decision making, and are not meant to represent the only or best course of care, or replace clinical judgment. Therapeutic options should be determined after discussion between the patient and their care provider. Clinicians and patients should weigh and integrate the information provided by the app in the context of other considerations, including recommended lifestyle interventions, patient preferences for taking medications, potential adverse drug reactions or interactions, and the likelihood of success of a treatment intervention for a particular patient.

The name "ASCVD Risk Estimator Plus" represents that the updated app is a combination of the original ASCVD Risk Estimator functionality plus the 2016 Million Hearts Longitudinal ASCVD Risk Assessment Tool published in 2016, and additional up-to-date guideline recommendations. The new app also has an updated design consistent with ACC's clinical app portfolio.

ASCVD Risk Estimator Plus maintains the core functionality of the original ASCVD Risk Estimator (e.g., users can still directly calculate a patient's 10-year ASCVD risk via the Pooled Cohort Equation and review guideline recommendations on statin initiation).

The new ASCVD Risk Estimator Plus includes additional capabilities to project potential benefit of specific risk-lowering interventions (statins, blood pressure medication, aspirin, smoking cessation), and the capability to update and track change in risk over time based on a patient's actual response to interventions. Additionally, ASCVD Risk Estimator Plus has additional recommendations from multiple ACC/AHA guidelines, including the 2017 High Blood Pressure Guideline and 2019 Primary Prevention Guideline.  New features include a bar graph that shows all risks calculated within the app, and additional references and resources such as a sample use case, and a glossary of terms and concepts.

Initial 10-year ASCVD risk, either at a first visit, or a previous visit being used for comparison, is calculated via the Pooled Cohort Equation published as part of the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. The updated 10-year ASCVD risk at follow-up visits and projected 10 -year ASCVD risk values are derived from the 2016 Million Hearts Longitudinal Risk Assessment Tool published as part of the "Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool" User Guide. Therapy advice is derived from the 2019 Primary Prevention Guideline, 2018 Cholesterol Guideline, 2017 High Blood Pressure Guideline and is supplemented by the Million Hearts Longitudinal Risk Assessment User Guide.

Lifetime ASCVD Risk at Initial Visit:
Estimates of lifetime risk for ASCVD are provided for adults 20 through 59 years of age and are shown as the lifetime risk for ASCVD for a 50-year old without ASCVD who has the risk factor values entered at the initial visit. Because the primary use of these lifetime risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Estimated 10 Year ASCVD Risk

• At Initial Visit: Calculated using the ACC/AHA 2013 Pooled Cohort Equation, which predict the absolute 10-year ASCVD risk for a patient with the profile entered at initial visit. This calculation is the same as it is in the ASCVD Risk Estimator.
• At Follow-up Visit: Updated 10-year ASCVD risk is a function of the initial visit risk, the age of the patient at the follow up visit, and the interim change in therapies and risk factor levels, which are themselves a function of response to therapy and adherence. The confidence of the updated on-treatment risk estimate is improved by scaling the risk reduction to the amount of change in SBP or LDL-cholesterol or duration of smoking cessation. The values for the actual updated 10-year ASCVD risk estimate also have floor and ceiling values applied. The floor value is calculated as the predicted 10-year ASCVD risk for someone with optimal risk factor levels at the follow-up age. A patient's 10-year ASCVD risk at follow-up will not be calculated to a value below this floor value. The ceiling value is the predicted 10-year ASCVD risk calculated from the actual updated risk factor profile, including use of medications.

Projected 10-Year ASCVD Risk with Initiation of Therapy

• At Initial Visit: Numbers on the Therapy Impact Tab when in Initial Visit mode represent the projected 10-year ASCVD risk that would be associated with the application of specific preventive therapies as designated for each row by the scenarios selected by the user. These estimates are a function of the estimated 10-year ASCVD risk at initial visit for the patient and the expected average relative risk reduction associated with a given therapy experienced by participants in randomized clinical trials, using systematic review data described in the original Million Hearts Longitudinal ASCVD Risk Assessment Tool manuscript. In instances where a therapy is not advised or relevant for a given patient based on the profile entered (e.g., smoking cessation for a patient who has never smoked), the forecasted risk for this therapy will be displayed as "NA".
• At a Follow-Up Visit: The risk reduction impact from the initiation of certain therapies can currently only be projected from risk at an initial visit, and is not available for follow-up risk.

AHA/ACC guidelines stress the importance of lifestyle modification as the foundation to lowering cardiovascular disease risk. This includes eating a heart-healthy diet, regular aerobic exercises, maintenance of desirable body weight and avoidance of tobacco products. The evidence-base for this specific app focused on average patient responses to the ABCS therapies (aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation). Quantification of benefit from individual therapeutic lifestyle interventions was out of the scope of the source documents for this app. However, the app is intended to guide decision-making around ABCS in the context of, and in addition to, recommended lifestyle interventions. Benefit from lifestyle intervention is reflected in the App's risk calculation through the "credit" given for improvement of a patient's LDL-C and systolic blood pressure, regardless of how that improvement was achieved.

The ASCVD Risk Estimator Plus is free for both ACC members and non-members.

• To download on a mobile device (Apple or Android), search "ASCVD Risk Estimator Plus" in the iTunes or Google Play app stores.
• The access on the web, go to: tools.acc.org/ASCVD-Risk-Estimator-Plus
• If you have already have version 1.0 of the ASCVD Risk Estimator on your Apple or Android device, and it has not yet upgraded to the ASCVD Risk Estimator Plus, check the appropriate settings to manually update the app.

The ASCVD Risk Estimator Plus was adapted in collaboration with the clinician work group who developed the original ASCVD Risk Estimator, as well as input from authors of all the relevant source documents. Testing of the app included review and feedback from a variety of clinicians, including cardiologists, pharmacists, and primary care physicians.

Content in the app will be updated to reflect any changes to its source document and the related clinical environment. Relevant relationships to other existing ACC clinical policy documents and resources will also be considered in future updates. Ongoing user feedback helps identify needs and opportunities for future updates.

You can provide feedback and suggestions about the app in two ways:

1. Complete the ACC's feedback survey here, which is also accessible through the "About the App" section in the app.
2. Leave comments on the iTunes or Google Play page for the app.

The ACC is also collecting data about the app through analytics, usability studies, and impact studies when possible. Feedback is used to ensure the app's accuracy and to identify opportunities for improving the app's user experience and to inform the ACC Mobile App Framework.

The app's intended target audience is clinicians involved in managing a patient's risk factors for atherosclerotic cardiovascular disease (ASCVD), particularly LDL-C and blood pressure levels. ASCVD is defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke. The app can also be used by patients, and contains a resource section specifically designed for patient use. The app is also designed to be used by both clinicians and patients together, to facilitate a discussion around a risk-lowering intervention plan that best matches patient preferences and individualized treatment goals.

The app is freely available to all users on the web and for download in the Apple and Android stores. Patients may find the app helpful in monitoring their own ASCVD risk. To facilitate this, the Resource section of the app includes a variety of resources targeted specifically for a patient audience. In addition, the app is designed to be used by both clinicians and patients together, to facilitate a discussion around a risk-lowering intervention plan that best matches patient preferences and individualized treatment goals.

No patient information is collected and stored in the app. Anonymous user behavior (e.g., number of people who downloaded the app, how many times a day the app was used) will be gathered through Google Analytics. All data collected in the app is anonymous and cannot be traced back to an individual user.

The ASCVD Risk Estimator Plus is a translation and a companion tool to the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, the 2018 ACC/AHA et.al Guideline on the Management of Blood Cholesterol, the 2017 ACC/AHA et.al Guideline on High Blood Pressure in Adults, the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk, and the 2016 ACC/AHA Special Report: "Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool."  The content of all documents and the resulting app were informed by input from a variety of specialists. The app is intended to be used in concert with ACC's other cholesterol and ASCVD risk management clinical policy and tools, particularly the LDL-C Manager app. The App is also part of the ACC Clinical Mobile App Collection designed to be used "on the go" to help optimize patient care. More information about ACC's Clinical App Collection can be found here.

While the ASCVD Risk Estimator Plus app itself was developed by, and is solely a product of, the American College of Cardiology, the source documentation and policy were developed jointly by the ACC and the American Heart Association.

The app has an email function for users to send a summary of their individual app sessions to a recipient of their choice which can then be transferred into EMR notes.

Contact the ACC at 1-800-253-4636 or membercare@acc.org.