Timothy Plante, MD

Dr. Plante is a general internal medicine fellow at the Johns Hopkins University School of Medicine.

Last month we discussed the clinical evidence summary app (CESA) 

which summarizes and criticizes internal medicine literature. CESAs focusing on cardiology subspecialities have been around for several years. (Sadly, the excellent CHF Trials app is now unavailable.) ACS Trials is one such cardiology-focused CESA that covers literature related to ACS and stable CAD. It is available for iOS for $2.99.

	ACS Trials was developed by a group of clinicians primarily at Washinton University. St. Louis. It combines its database of trial interpretations with a selection of medical calculators. Let’s start with the trial database.

	ACS Trials’ database boasts >80 high-impact summaries of RCTs of interventions and medications related to ACS and stable CAD. Each summary starts with a brief ‘Take Home Message’, which is a short interpretation of the trial, then the ‘Summary’ section, which discusses each trial in the context of the greater medical literature. The subsequent sections cover the meat of the trial, namely design, inclusion/exclusion criteria, and methods. The baseline characteristics and endpoint data sections present number-heavy subjects in easy-to-digest pieces. ACC/AHA guidelines are incorporated when relevant, but it isn’t apparent which year’s guidelines are presented. The end of the summary is links to PubMed and the publisher’s site.

The database can be sorted by trial name, subject, drug, and year of publication. Sorting by year reveals that only one trial published since 2013 has been added to the database. 

	The app includes 34 medical calculators relevant to cardiology and a handful of non-cardiology ones that are somewhat out-of-place (eg, SIRS criteria). Unfortunately, the cardiology-relevant calculators incomplete and out of date. For example, the device contains an ATP III guideline management algorithm and CHADS

 calculator, but lacks an ASCVD 10 year risk estimator and CHA

-VASc and HAS-BLED calculators. The calculators included are easy to use and include bonus references to validation studies.

	ACS Trials updates its database with each app revision, which occurred 10 times between 2011-2014 but only once in 2015. This means that the content hasn’t been expanded in over a year. Will there be updates in the future? If the app’s support page is any indication – it doesn’t look good since it’s a Squarespace 404 error page.

 Emails to the developer did not receive a response.

	ACS Trials is a handy database of classic trials for ACS and stable CAD. It also has some calculators, but this pales in comparison to dedicated calculator packages like MDCalc.

 The trial database is very useful but needs an update. Hopefully we’ll see one soon.  One commenter noted on the iTunes page that he would have given [the app] 5 stars if the content was current. “Otherwise,” the comment notes, “a history book of ACS science. Nonetheless, worth the money.” I agree.

Articles

This "history book of ACS science" is a worthwhile download for the busy cardiologist.

Cardio App of the Month: ACS Trials

	Smoking cessation is integral to comprehensive prevention of cardiovascular disease (CVD). Even when patients are motivated, and we as clinicians find the time to provide counseling, successful smoking cessation is still far from 100 percent. To address this, the National Cancer Instituteâs Tobacco Control Research Branch started the 

project. This free website showcases an impressive array of technologies to help Americans quit smoking using evidence-based behavioral strategies. One of the most impressive technologies on the site is the 

QuitGuide is an intuitive, free smoking cessation app intended to help users quit smoking or help those who recently quit to avoid restarting. Its content follows the US Clinical Practice Guidelines for tobacco use and dependence (2008 update.

	Initial setup only takes a minute or two. Upon opening the app, the user customizes the experience by entering a quit date, identifying a motivation for quitting, and uploading a motivational image (eg, a picture of a child, grandchild, etc). Patients can enlist the help of friends and family by sharing their quit plan through social media platforms (eg, Facebook) with just a single click. Since the setup is so quick and easy, and mirrors common themes in an office-based smoking cessation intervention, a clinician can easily integrate the setup of this app into an office visit. (The install file is 20 mb, which means it probably isn't prohibitively large for patients with typical data plans.)



	The main screen of QuitGuide (Figure, left) prominently displays a countdown until a quit date has been reached if it is in the future or days since quitting if it is in the past. Users can either select a button that says "I was Smokefree today" or "I slipped." Selecting "I slipped" prompts the user to identify the trigger like drinking coffee, taking a work break, finishing a meal, or driving. Back on the main screen, there is a "Track My Craving" option which opens a screen (Figure, right) where one can identify the strength of craving on a 10-point scale and a specific trigger, for which the app will offer simple strategies to minimize risk of relapse. For example, if a user identifies a craving level of between 1 and 5, and identifies coffee drinking as the trigger, then the app will suggest trying teeth brushing immediately after finishing the cup. Hopefully these helpful suggestions will be integrated into the "I slipped" trigger logging in future updates.





	Helpful information and quitting strategies are ubiquitous in the app. On the home screen is a cycling of "quitisms,"or introspective thoughts about the process of quitting smoking. Tucked in the menu is a thorough overview of the quitting  process. Sprinkled throughout other screens are reaffirmations and other behavioral tips, similar to the trigger tips. The developers should be applauded for how these informational resources appear in an organic way, rather than as in-your-face, spammy popups. Moreover, users can opt to have push notifications with customized information or prewritten messages appear either at a specific time or specific GPS location.



	Navigating from the main screen, users can also manage their mood by selecting one of nine options ranging from happy to stressed 

). For more positive moods, users can write a journal entry or take a photo for later. For more negative moods, users are given options to see tips and distractions, view notes and photos from more pleasant moods, add a new entry in their journal, or a suggestion to call a friend.





	For more data-driven smokers, QuitGuide provides some clever visualizations of data entered. The history tab shows a calendar with days in red for slips and green for smoke free days. Users can examine a day-by-day listing of moods, cravings, and triggers. Users can further explore frequencies of logged moods and see a breakdown of events that were associated with lapses or cravings. The app gamifies data as well, giving trophies and presenting the estimated dollar savings from not buying cigarettes, and amount of time saved by not smoking (Figure above, right).





	We are very impressed by QuitGuide. While it warrants formal clinical trial evaluation, in the absence of such data, we see little downside to trying the app with patients and big potential for upside. It is an intuitive, adaptable, and educational app that is built on smoking cessation theory. It is available free of charge from a reputable source and follows existing guidelines. Probably most surprising is how few downloads this app has--only 5,000 to 10,000 for Android. The next time you counsel a patient about smoking cessation, ask if they have a smart phone. If they do, have them download this app and set it up with you in the moment! We think youâll be as impressed as we were.

All images courtesy of the National Cancer Institute. 

The smoking cessation app called QuitGuide may help make this time the last time for some of your patients.

App Review of the Month: QuitGuide

 redefined management of lipids and brought with them the Atherosclerotic Cardiovascular Disease (ASCVD) risk âestimatorâ 

. Note the purposeful use of the term âestimator,â rather than âcalculator,â a choice intended to convey the point that the result is an approximation of ASCVD risk rather than an exact determination of risk in an individual. Much has been written about the ramifications of the specific changes detailed in these new guidelines. Love them or hate them, these guidelines have changed practice.

	The equation at the heart of the estimator was derived from a Pooled Cohort of NIH-sponsored studies (ARIC, CHS, CARDIA, Framingham Original, and Framingham Offspring)

 and attempts to estimate risk for fatal and non-fatal MI and stroke for individuals using sociodemographics and traditional risk factors. Unlike counting up the risk points from ATP III, there is no way that you are going to be able to get to the risk estimate in your head. Fortunately, you donât have to.

	The ACC/AHA ASCVD Risk Estimator app was developed by the American College of Cardiology foundation and first released in early 2014. It is available for Apple and Android smart phones and tablets for free at their respective online stores. This user-friendly app is geared to both medical professionals and patients. Itâs designed to help provide a sense of 10-year ASCVD risk for patients aged 40-79 years and lifetime ASCVD risk for those aged 20-59 years. Itâs engineered to be efficient and intuitive, which means it can be incorporated into a clinical encounter. Let's take a closer look.

 screen. Enter the sex, age, race, total cholesterol, HDL cholesterol, and SBP, then indicate whether the patient is on HTN therapy, has a history of DM, or is a smoker. Data entry is quick, unless you need to use a third-party calculator to convert to SI units, which arenât supported in the current version of the app. (You can also be slowed down a bit if you have to manually delete information from the last patient as there is no reset button.) After completing data entry, up pops an estimation of 10-year and lifetime risk. Importantly, it also presents, for comparison, the estimated risk for a similar person with optimized risk factors.

	Importantly, the risk estimation is linked to clinical recommendations from the AHA/ACC guidelines. The 

 tab is essentially an FAQ of ASCVD risk estimation. Does your patient qualify for moderate-intensity statin and you want to review each of the possible medication choices? Select 

âIntensities of Statin Therapyâ

 to see what you can use. Not sure about the latest recommendations for lifestyle changes when initiating statin therapy? Check out 

for information on diet, weight management, physical activity, and smoking cessation.

 patient portal with educational overviews of ASCVD as well as information on behavioral changes like weight loss and dietary modifications. This feature isnât designed so that patients can create a profile that will save their ASCVD risk score or get directed advice. Still, motivated patients may find this part useful.

	For those interested in taking a deeper dive into the complexities underlying the ASCVD Pooled Cohort Equations, the website 

 has some excellent visualization tools, including an animated 3D graph. Using a modern browser, head to 

	We both routinely use the ACC/AHA ASCVD Risk Estimator in our clinical practices. We find it to be a convenient tool that helps us as busy clinicians engage our patients in shared decision making and deliver guideline-based care.

	Goff DC, Lloyd-Jones DM, Bennett G, et al.

 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

. Circulation. 2013. Published online before print November 12 2013, doi:10.1161/01.cir.0000437741.48606.98

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

http://tools.acc.org/ASCVD-Risk-Estimator/

The practice of CVD risk estimation shifted radically in 2013. The ACC-AHA app helps you connect the new dots.

Timothy Plante, MD

Articles

Cardio App of the Month: ACS Trials

App Review of the Month: QuitGuide

App Review: The ACC-AHA ASCVD Risk Estimator