By Steve Wong, MD, FRCPC (biography and disclosures)
What I did before
In counseling patients regarding their lipids, where appropriate, I strive to discuss risks and benefits of pharmacologic therapy, including a cardiac risk assessment. Although I recognize its limitations, the Framingham Risk Score remains central to most guidelines, including the Canadian Cardiovascular Society lipid guidelines. Given time constraints, especially in my perceived low risk or low-moderate risk patients, I often found myself estimating patient risks instead of actually taking out the scoring tool and adding up the points.
In addition, patients are often resistant to adding yet another medication to their existing regimen. Occasionally, I’ve had low risk patients who were very keen on taking statins “just in case.” Hard numbers often help make the decisions in these patient groups.
This app changed my practice
In the Palm Pilot days (a long-discontinued handheld personal digital assistant), I used various Framingham score tools. With the torrent of apps now available for the iPhone, I looked for an app with direct applicability to Canadian physicians, using SI units and recommendations consistent with the CCS guidelines. In the last year, the CCS released their mobile lipid guideline app (iPhone/iOS only).
This app allows a very rapid entry of relevant parameters to perform risk assessments using the Framingham Risk Score but also the Reynolds Risk Score (which takes into account family history and hs-CRP, but is for use in non-diabetic patients – more information is available at http://www.reynoldsriskscore.org/). There is also a calculator to determine if your patient meets criteria for the metabolic syndrome.
As you enter values into the tool, the slider on the bottom moves up to show the 10 year risk for a cardiac event. In addition, the “Show Treatment Info” tab just above the slide rule pops up the recommended treatment thresholds and targets for the calculated risk.
Other useful aspects of the app include summaries of the actual CCS 2009 lipid guidelines, as well as discussions about the difference between the Framingham and Reynolds risk scores, and information about the CCS’s approach to the metabolic syndrome.
The CCS 2009 Lipid Guideline apps is available for free from the iTunes App store.
http://itunes.apple.com/ca/app/ccs-lipid-guidelines/id394804422?mt=8&uo=4
What I do now
Because of the simplicity and speed of data entry, I now use this app whenever I need to perform a risk cardiac assessment on a patient. Not surprisingly, I found that my own estimations were often incorrect (both over- and under-estimating), and this tool provides a convenient check against my own assumptions.
Whether or not you choose to apply the CCS guidelines, or accept the validity of the metabolic syndrome is beyond the scope of this article, but I have found the scores generated by the app greatly help in patient decisions. The moving slider on the bottom is quite illustrative for patients, and the pop-up windows showing treatment thresholds and targets has helped me convince patients to either start or, in some cases, not take, lipid lowering therapies.
We need more tools that help apply guidelines and current evidence, in a user-friendly and efficient manner. The CCS lipid app is a great illustration of this.
You can see the other CCS apps at this link (note: as of Jan 2012, the CCS does not make any Android apps):
http://www.ccs.ca/guidelines/mobile_apps_e.aspx
References
- CCS 2009 Lipid guidelines (pdf download) http://www.ccs.ca/download/consensus_conference/consensus_conference_archives/2009_Dyslipidemia-Guidelines.pdf
- CCS mobile apps http://www.ccs.ca/guidelines/mobile_apps_e.aspx
- Reynolds Risk score http://www.reynoldsriskscore.org/faq.aspx
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Since I use EMR in the office, are the results printable or able to be attached as a document to the patient file?
What a wonderful way to be confidant about the results. This makes patient conselling straightforward giving the patient confidence in your advise
Unfortunately, the app does not have printing ability. If you want, you can take a screenshot of the calculation, then transfer the image to the EMR (to take a screenshot, you press the front screen button and power button at the same time). This seems like more work than it’s worth.
I agree that a visual is helpful for patients to understand.
aim to download now.
do use a paper version at present
Thanks for the review. I am the author of this CCS mobile guideline app. Great suggestion to add a printable/PDF version or the calculation output in the next version.
If you like this app, you should also check out the CMR App by the Canadian Cardiometabolic Risk Group. It is available in iOS, Android, Blackberry and the web (cmrapp.com).