Cardiac Risk Assessments by cuiliqing

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									                                                               RISK CALCULATORS
Assessment of risk in 1y Prevention                                 Framingham Risk Score

Pre-test probability of CHD                                        Duke Clinical Risk Score
in stable Chest Pain
Post-test probability of CHD                                      Duke Treadmill Test Score
in stable Chest Pain
Initial Risk in ST elevation MI                              TIMI Risk Score in ST elevation MI
Initial Risk in Unstable Angina
or non-ST elevation MI                                        TIMI Risk Score in UA / NSTEMI

Risk in Acute Coronary Syndrome                            Risk in ACS derived from ExECG+TnT
using ExECG+TnT
Risk of Cardiac Surgery                                           EuroSCORE & Parsonnet

"Choice" Priority for CABG                                       "Choice" Priority for CABG


Risk of Stroke in AF (Warfarin/Aspirin)                       Risk of stroke in AF (?Warfarin)

                                                           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 Hospital, Herts HP2 4AD
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                                                       Home

                                                                                                                           Planned or actual change in risk factors
Age                   (limits are 35-74 for CHD risk, 55-85 for Stroke risk)     55        35-85 yrs                         55                                55
Total Cholesterol                                                                 5         mmol/l                            5        +0%                      5                                 +0%
HDL Cholesterol                    (if unknown use Male=1.1, Female=1.4)         1.1        mmol/l                           1.1       +0%                     1.1                                +0%
Systolic BP                                                                     140         mmHg                            140        +0%                    140                                 +0%
In Atrial Fibrillation ?                                                          0        0=N, 1=Y                           0                                 0
On AntiHypertensive Rx ?                                                          0        0=N, 1=Y                           0                                 0
History of Smoking in past year ?                                                 0        0=N, 1=Y                           0                                 0
History of Diabetes ?                                                             0        0=N, 1=Y                           0                                 0
History of CHD,CHF or Peripheral Vascular disease ?                               0        0=N, 1=Y                           0                                 0
ECG LVH ?                (if unknown, try 0=N and 1=Y to see range of risk)       0        0=N, 1=Y                           0                                 0
                                                                                Male       Female                           Male     Female                   Male                             Female
Calculated 10 year risk of CHD event                                           11.7%        7.6%                           11.7%      7.6%                   11.7%                              7.6%
Average 10 year risk of CHD event at this age                                   16%         12%                             16%        12%                    16%                               12%
"Ideal" 10 year risk of CHD event at this age                                   6%           4%                              6%        4%                      6%                                4%
Relative risk of CHD vs Average risk                                             0.7         0.6                             0.7        0.6                    0.7                               0.6
Relative risk of CHD vs Ideal risk                                               1.9         1.9                             1.9        1.9                    1.9                               1.9
Change in risk of CHD event                                                                                                  0%        0%                      0%                                0%
Calculated 10 year risk of Stroke                                              3.9%          2.0%                           3.9%      2.0%                    3.9%                              2.0%
Average 10 year risk of Stroke at this age                                      6%            3%                             6%        3%                      6%                                3%
Relative risk of Stroke vs Average risk                                         0.7           0.7                            0.7        0.7                    0.7                               0.7
Change in risk of Stroke                                                                                                     0%        0%                      0%                                0%
Calculated 10 year risk of Cardiovascular event                                15.5%         9.6%                          15.5%      9.6%                   15.5%                              9.6%
                            Hypercholesterolaemia
     Advice                 HDL cholesterol
      from                  Hypertension
    Guidelines              Anticoagulation in AF to reduce risk of Stroke
                            Validity of CHD Risk calculation
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
Framingham Risk Calculations: "Ideal" risk                                             Expected 10 year probability of CHD Event
                                                                                            Age        Avg M      Ideal M    Avg F                   Ideal F
                                                                                              30         0.03        0.02     0.005                    0.005
                                                                                              35         0.05        0.03     0.005                    0.005
                                                                                              40         0.07        0.03      0.02                     0.01
                                                                                              45         0.11        0.04      0.05                     0.02
                                                                                              50         0.14        0.05      0.08                     0.03
                                                                                              55         0.16        0.06      0.12                     0.04
                                                                                              60         0.21        0.08      0.12                     0.04
                                                                                              65         0.28         0.1       0.1                     0.04
                                                                                              70         0.23        0.13      0.11                     0.03
                                                                                              74         0.23        0.13      0.11                     0.03

                                                                                       Expected 10 year probability of Stroke
                                                                                            Age        Avg M       Avg F
                                                                                              55        0.059        0.03
                                                                                              60        0.078       0.047
                                                                                              65         0.11       0.072
                                                                                              70        0.137       0.109
                                                                                              75         0.18       0.155
                                                                                              80        0.223       0.239

Guidance "rules"
TC (FH)               If Total Cholesterol >7.5, consider FH
HDL                   If HDL <0.9, risk of atheroma is increased
BP                    If SBP 140-159,consider drug Rx if CHD risk >15% or DM, CV complications or Target Organ Damage(eg LVH), but if SBP >=160 consider drug Rx for Hypertension: Target<140/90
AF                    If AF AND ((Annual stroke risk =>6% so 10yr risk =>60%) OR (presence of another risk factor {age >75, Hypertension,Hypercholesterolaemia, Smoker, Diabetic or known CHD,CHF or PVD})
                           consider Warfarin, if just lone AF consider Aspirin
CHD risk calculation not valid if patient has FH (suggested by TC >7.5) or known CHD
hire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD
60 consider drug Rx for Hypertension: Target<140/90
 esterolaemia, Smoker, Diabetic or known CHD,CHF or PVD})
        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
        55
        Age                  (original data derived from ages 30-70)  55
        Sex                                                            0 0=M, 1=F
        0
    1   Precipitated by exercise                                       0 0=N, 1=Y
    2   Brief duration (2-15min)                                       0 0=N, 1=Y
    3   Relieved promptly by rest or GTN                               0 0=N, 1=Y
    4   Retrosternal                                                   0 0=N, 1=Y
    5   Radiating to jaw, neck or L arm                                0 0=N, 1=Y
    6   Absence of other cause                                         0 0=N, 1=Y
                                   Chest Pain Categorised as: None/Non-Anginal
A          Probability of significant CHD (ACC/AHA Guidelines):      20%

  0
  Smoking (within past 5 years)                                                             0              0=N, 1=Y
  Total Cholesterol                                                                         5               mmol/l
  Diabetes                                                                                  0              0=N, 1=Y
  Previous MI                                                                               0              0=N, 1=Y
  ECG: Q waves                                                                              0              0=N, 1=Y
  ECG: ST changes at rest                                                                   0              0=N, 1=Y
B               Probability of significant CHD (Duke):                                     23%
                             (>75% stenosis of at least 1 major coronary artery)
                                       Exercise Test usually not indicated                                                     Set thresholds for ExECG



        References:
A       Gibbons RJ et al. ACC/AHA/ACP-ASIM Chronic Stable Angina Guidelines                       JACC 1999;33:2092–197
         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
B       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 advice regarding indication for ExECG
        Probability below which ExECG NOT indicated                                                               0.25
        Probability above which ExECG indicated only for prognosis                                                0.75
Pretest Likelihood of CHD in Symptomatic Patients According to Age and Sex
                                                       Nonanginal Pain    Chest Pain ? Cause
                                          Mean Age     Men      Women       Men      Women
                                                  35       4%         2%      34%        12%
                                                  45      13%         3%      51%        22%
                                                  55      20%         7%      65%        31%
                                                  65      27%        14%      72%        51%
                                                  75
References
Gibbons et al. ACC/AHA/ACP-ASIM Chronic Stable Angina Guidelines JACC 1999;33:2092–197
Diamond GA, Forester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300:1350 –1358.
Chaitman BR, Bourassa MG, Davis K, Rogers WJ, Tyras DH, Berger R, Kennedy JW, Fisher L, Judkins MP, Mock MB, Killip T.
 Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation 1981;64:360 –367.



    Intermediate calculations (Duke)
    Angina score                                                                   0
    Angina type                                                                    0
    Angina: Typical                                                                0
    Angina: Atypical                                                               0
    Hypercholesterolaemia: TC>6.5                                                  0
    Age*Sex                                                                        0
    Age*Smoking                                                                    0
    Age*Hyperchol                                                                  0
    Sex*Smoking                                                                    0
    MI*Q                                                                           0
    Interactions                                                                   0
    x                                                                         -1.183
    e-x                                                                       3.2642
    1/(1+e-x)                                                              0.234513
                                                                           0.234513
                               Set thresholds for ExECG




 sis of coronary-artery disease. NEJM 1979;300:1350-8
e in patient subsets (CASS). Circulation 1981;64:36-7
nary artery disease Am J Med 1983;75:771-80



ng patients at increased risk for CAD Ann Int Med 1993;118:81-90
                                                 Typical Angina
                                                 Men      Women
                                                   76%        26%
                                                   87%        55%
                                                   93%        73%
                                                   94%        86%



coronary-artery disease. N Engl J Med. 1979;300:1350 –1358.
Duke Treadmill Score: Predictions of CHD in a patient with chest pain undergoing ExECG
NOTE: This score is not applicable if patient is known to have CHD                                                    Home
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                                       19%          probability of >75% stenosis in at least 1 coronary artery
Probability of Severe CHD                                            15%          probability of 3 vessel CHD or >75% LMS
5yr Mortality                                                        14%

Overall risk subcategory                                           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
West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD
TIMI Risk Score for ST Elevation Acute MI (STEMI)
Patient with ST elevation MI                                                                      Home
= Chest pain > 30min, symptom onset <6hrs ago, ST elevation, no contraindication to thrombolysis
HISTORY
Age                                                                                 50    (years)
History of Angina                                                                    0    (0=N, 1=Y)
History of Hypertension                                                              0    (0=N, 1=Y)
History of Diabetes                                                                  0    (0=N, 1=Y)
EXAMINATION
Systolic Blood Pressure < 100                                                        0    (0=N, 1=Y)
Heart Rate > 100                                                                     0    (0=N, 1=Y)
Killip Class II-IV * (ie clinical heart failure)                                     0    (0=N, 1=Y)
Weight < 67 kg (< 150 lb)                                                            0    (0=N, 1=Y)
PRESENTATION
Anterior ST Elevation or LBBB                                                        0    (0=N, 1=Y)
Time to treatment > 4 hours                                                          0    (0=N, 1=Y)

Total Risk Score                                                                               0
Risk of Death by 30 Days                                                                     0.8%
                                                                                           Low Risk
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


Designed by Dr John Bayliss (1999-2002) v11                   West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD
0
0    0
0
0

0
0
0
0

0
0

    0.8
TIMI Risk Score for Acute Coronary Syndrome (UA / NSTEMI)
Patient with Unstable Angina (UA) or non-ST elevation MI (NSTEMI)                                                      Home
= ischaemic pain within past 24hrs with ST deviation and/or +ve cardiac marker
HISTORY
Age (years)                                                                                      50          (years)
Current Smoker                                                                                   0           (0=N, 1=Y)
History of Hypertension                                                                          0           (0=N, 1=Y)
History of Hypercholesterolemia (TC > 5mmol/l)                                                   0           (0=N, 1=Y)
History of Diabetes                                                                              0           (0=N, 1=Y)
Family History of Coronary Artery Disease                                                        0           (0=N, 1=Y)
Prior angiographic stenosis >50%                                                                 0           (0=N, 1=Y)
Use of aspirin within the last 7 days                                                            0           (0=N, 1=Y)
PRESENTATION
Severe anginal symptoms (>= 2 episodes of rest pain in past 24 hours)                             0          (0=N, 1=Y)
ST deviation (horizontal ST depression or transient ST elevation >= 1 mm)                         0          (0=N, 1=Y)
Elevated cardiac markers (either CKMB or cardiac troponin)                                        0          (0=N, 1=Y)

Total Risk Score (0-7)                                                                        0
Risk of Death/MI by 14 Days                                                                  3%
Risk of Death/MI/Urgent Revascularization by 14 Days                                        4.7%
                                                                                          Low Risk
from TIMI 11B trial : Antman et al JAMA 2000;284:835-842
see www.timi.tv




Designed by Dr John Bayliss (1999-2002) v11                  West Hertfordshire Cardiology, Hemel Hempstead Hospital, Herts HP2 4AD
0
0   0
0
0
0
0
0
0

0
0
0
Risk of Cardiac Death or MI at 5 months after Unstable Angina / ACS

                                                                                                     Risk of Cardiac Death or MI at 5 months
Exercise ECG                                                                                                       Troponin T
ExECG Risk category                    Result                                                        >0.2mg/l      0.2-0.06mg/l     <0.06mg/l
                                       Low maximal workload (Less than Bruce II,
High Risk
                                       <=3min), AND ST depression >= 0.1mV in >= 3
                                                                                                       34%                     19%                       22%
                                       leads
                                       EITHER a low maximal workload achieved,
Intermediate Risk
                                       OR ST depression >= 0.1mV in >= 3 leads
                                                                                                       16%                      9%                        7%
                                       Low maximal workload exceeded,
Low Risk
                                       AND without ST depression >= 0.1mV in >= 3
                                                                                                        5%                      7%                        1%
                                       leads
?                                      Unable to perform exercise ECG                                  27%                     16%                        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                                                                       50    yrs
E,P Sex                                                                        0    0=M, 1=F
    CLINICAL RISKS
  P Smoker                                                                      0   0=N, 1=Y
  P Hypercholesterolaemia                                                       0   0=N, 1=Y
  P Hypertension                                                                0   0=N, 1=Y
  P Diabetes                                                                    0   0=N, 1=Y
  P Obesity                                                                     0   0=N, 1=Y
  P Family History of CHD                                                       0   0=N, 1=Y
    CLINICAL FEATURES & COMORBIDITY
  P Aortic Valve Disease                                                        0   0=N, 1=Y
  P Mitral Valve Disease                                                        0   0=N, 1=Y
E   LV Ejection Fraction                                                        0   2:<30%, 1:30-49%, 0:>=50%
E   Serum creatinine > 200 µmol/ L                                              0   0=N, 1=Y
E   C.O.P.D.                                                                    0   0=N, 1=Y
E   Systolic PAP > 60 mmHg                                                      0   0=N, 1=Y
E   Unstable angina                                                             0   0=N, 1=Y
E   Recent myocardial infarction (< 90 days)                                    0   0=N, 1=Y
  P LV Aneurysm                                                                 0   0=N, 1=Y
  P Preop IABP                                                                  0   0=N, 1=Y
E   Active endocarditis                                                         0   0=N, 1=Y
E   Neurological dysfunction                                                    0   0=N, 1=Y
E   Extracardiac arteriopathy                                                   0   0=N, 1=Y
E,P Previous cardiac surgery                                                    0   0=N, 1=Y
E,P Critical preoperative state                                                 0   0=N, 1=Y
    TYPE OF SURGERY
E   Emergency (within 24hrs)                                                  0     0=N, 1=Y
E,P Other than isolated C.A.B.G.                                              0     0=N, 1=Y
E   Surgery on thoracic aorta                                                 0     0=N, 1=Y
E   Postinfarct. septal rupture                                               0     0=N, 1=Y
    EUROSCORE predicted mortality (logistic)                               0.8%
    Parsonnet predicted 30 day mortality                                   0.9%
    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)


    Calculations in cells B100:F104 - DO NOT EDIT or DELETE!




                                                       Calculations                               EUROSCORE                                               Parsonnet
                                                            Sum betas                                         0                           Sum betas            2.383
                                                                 Logit                                -4.789594                                 Logit         -4.649
                                                              e^(logit)                            0.008315833                              e^-(logit)     104.4805
                                                  e^(logit)/(1+e^logit)                             0.00824725                         1/(1+e^-logit)       0.00948


    Euroscore sum betas
    =(IF(C2>59,(C2-59)*0.0666354,0))+(C3*0.3304052)+(C28*0.7127953)+(C15*0.6521653)+IF(C14>0,IF(C14=1,0.4191643,1.094443),0)+(C16*0.4931341)+(C30*1.159787)
    +(C24*0.6558917)+(C23*0.841626)+(C22*1.101265)+(C26*0.9058132)+(C18*0.5677075)+(C19*0.5460218)+(C17*0.7676924)+(C25*1.002625)+(C31*1.462009)+(C29*0.5420364)


    Parsonnet sum betas
    =(C2*0.054)+(C3*0.509)+(C5*0.089)+(C6*0.083)+(C7*0.263)+(C8*0.456)+(C9*-0.271)+(C10*-0.065)+IF(C14>0,IF(C14=1,0.542,0.813),0.271)+(C12*0.235)+(C13*0.835)
    +(C20*-0.553)+(C21*1.473)+(C26*1.455)+(C25*0.893)+(IF(C29=0,-0.588,0.647))
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                                                                                                     Score   ANGINA        1    0   Asymptomatic
Asymptomatic                                                                                                                               0   & ISCHAEMIA   2    2   CCS1 - No limitation of ordinary physical activity
SYMPTOM STABILITY                                                                                                                                            3    4   CCS2 - Ordinary physical activity causes discomfort
Stable on medication                                                                                                                       0                 4    6   CCS3 - Moderate to great limitation of ordinary phusical activity
LV FUNCTION                                                                                                                                                  5   10   CCS4 - Almost any activity causes discomfort. Angina at rest. Nocturnal angina
Good (EF>50%)                                                                                                                              0                 6    0   Normal Exercise test or Thallium scan
CORONARY ANATOMY                                                                                                                                             7    2   Equivocal Exercise test or Thallium scan
Normal                                                                                                                                     0                 8    5   Positive Exercise test or Thallium scan
Total Score                                                                                                                                0                 9   10   Strongly Positive Exercise test or Thallium scan
Should be suitable for choice
                                                                                                                                               STABILITY     1    0 Stable on medication
Cardiologists should fill in a scoring system to identify patient suitability for the choice initiative at the time of referral to surgeon                   2    5 Recent deterioration or angina at rest
The scoring system is a guide and an aid to decision making and the judgement of clinicians will be paramount.                                               3   10 Nocturnal angina
Score less than 20 :       Patient should be suitable for choice and should be informed at the time they see their
Score between 20 – 30 : Patient will probably also be suitable for choice
cardiologist.                                                                                                                                  LV FUNCTION   1    0 Good (EF>50%)
Score more than 30 :       Patient’s suitability for choice less easily determined by scoring system.                                                        2    4 Fair (EF 30-50%)
                             Clinician will need to make a judgement on an individual patient basis.                                                         3    6 Poor (EF<30%)

Extending Choice for patients: Information & Advice on establishing the Heart Surgery Scheme DoH 2002                                          COR ANAT      1   20   LMS >50%: L dominant or occluded R
www.doh.gov.uk/extendingchoice/index.htm                                                                                                                     2   15   LMS >50%
                                                                                                                                                             3   10   3VD with proximal LAD stenosis
                                                                                                                                                             4    6   3VD without proximal LAD stenosis
                                                                                                                                                             5    6   2VD with proximal LAD stenosis
                                                                                                                                                             6    4   Proximal LAD stenosis only (1VD)
                                                                                                                                                             7    1   1-2VD without LAD stenosis
                                                                                                                                                             8    0   Normal


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: 1852–1923          (www.acc.org/clinical/statements.htm)

CHADS2 Risk Score                                     (JAMA 2001,285:2864-2870)
Risk                                                   Points                                                                      Risk Score   Stroke Risk %
Congestive Heart Failure (past or present)               0                              (Y=1, N=0)                                          0              1.9
Hypertension             (past or present)               0                              (Y=1, N=0)                                          1              2.8
Age >=75                                                 0                              (Y=1, N=0)                                          2              4.0
Diabetes                                                 0                              (Y=1, N=0)                                          3              5.9
Stroke or TIA            (in past)                       0                              (Y=2, N=0)                                          4              8.5
                                       Risk Score        0                              (0 - 6)                                             5             12.5
         Annual risk of Stroke (rate per 100 pt-years)  1.9                                                                                 6             18.2
                                          Warfarin NOT indicated


SIGN - Antithrombotic Therapy Guidelines SIGN 1999 (No 36)
Table 1                                                               Annual Risk of Stroke in non-valvular AF
Group                                                                   UnRx          Aspirin       Warfarin                       NNT                           * Risk factors for thromboembolic stroke
Very High Risk                            Previous TIA/Stroke            12%            10%            5%                           18                           - Previous TIA/Stroke
High Risk                                >65 + Risk Factor(s)*          5-8%            4-6%          2-3%                          42                           - >65yrs
                                      >65 + No Risk Factor(s)*                                                                                                   - Hypertension
Mod Risk                                 <65 + Risk Factor(s)*             3-5%               2-4%                1-2%              71                           - Diabetes
Low Risk                               <65 + No Risk Factors*              1-2%                1%                 0.5%             142                           - Heart Failure
                          NNT=Number needed to treat with Warfarin instead of Aspirin for 1 year to prevent 1 stroke                                             - Echo LV dysfunction
BUT                       Annual risk of major bleed                       0.1%                1%                  2%           NNH=100                          - Echo MV calcification
                          NNH=Number needed to harm by treating with Warfarin instead of Aspirin for 1 year (causing a major haemorrhage)                        - (Echo LA>5cm) - not very predictive
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                  <65 + Risk Factor(s)*     3-5%          3-5%          3-4%
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                    <65 + Risk Factor(s)*        95%            96%              98%
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

								
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