Heart disease continues to be a leading cause of morbidity and mortality worldwide. As the prevalence of cardiovascular diseases rises, NHCS recognises the urgent need to increase awareness on heart disease prevention and empower individuals to take active steps towards understanding and managing their risk factors.

Prof Terrance Chua, Senior Consultant, Department of Cardiology, saw an opportunity to empower the general public and health practitioners with the knowledge to calculate heart disease risks, as a pivotal step toward preventing and managing this pervasive health issue. As such, NHCS began planning to incorporate digital ‘calculators’ on various platforms to support risk scores tailored for our Singapore population more than a year ago.

The most commonly used and the most referenced risk score calculator - Framingham Risk Score (FRS) has been well-established to assess individual’s risk of getting cardiovascular disease. Developed for the Western population, the FRS estimates a person’s 10-year risk of heart disease. The risk score was later recommended and enhanced by local healthcare professionals to be adjusted for use in Singapore for its local population. The risk score was subsequently localised and incorporated in the Ministry of Health’s clinical guidelines since 2011. The localised FRS has since been embedded in NHCS’ Cardiovascular Information System (CVIS) for the clinical team’s usage and reference. 

Screenshots of some of the risk calculators available in the CVIS.

Harnessing technology for better accessibility

With the advent of digital health technology and technology savviness in Singapore, a team of doctors saw the opportunity to develop a user-friendly application tool to make calculating heart disease risks easier and accessible for everyone. Led by Asst Prof Huang Zijuan, Consultant, Department of Cardiology, the team devised the tool using the localised FRS. This Heart Disease Risk Calculator aims to enable general public and health practitioners in partnering their patients to better understand their heart disease risks, as a pivotal step toward preventing and managing this pervasive health issue. 

A staunch advocate for patient health education, Asst Prof Huang consistently seeks ways to empower patients in taking charge of their health. “Knowledge is power. While we have access to useful tools and guidelines to help us manage patients’ risks, it is equally important to share credible resources which can benefit and empower our patients to make informed decisions about their health and actively participate in managing their own risks,” shared Asst Prof Huang. 

Victor Effendie, Senior Manager, Department of Solution Integration & Data Analysis who was involved in the implementation of the localised FRS in the NHCS CVIS, is also one of the members of the Heart Disease Risk Calculator project. In the initial phase of the project, Victor helped with the development of a simple formulated Microsoft Excel file which was made available on NHCS website for healthcare professionals to download and use.  

Screenshot of the localised FRS calculator in MS Excel on NHCS website, available since June 2022, for healthcare professionals’ usage.

Recognising the need to have the calculator in a more user-friendly format which is also suitable for the general public and patients, Asst Prof Huang initiated conversations with the team managing SingHealth’s Health Buddy App, on the feasibility to develop an application in the App. After a year of planning, working out the algorithms, simplifying the steps for better user-friendliness, and countless rounds of tests, the Heart Disease Risk Calculator feature was finally launched in July 2023.

The Heart Disease Risk Calculator, now available in SingHealth’s Health Buddy App, can predict one’s 10-year cardiac event risk and provide personalised, easy-to-understand health advice to manage one’s risk. It also allows visualisation of changes in risk as risk factors become better controlled. It is designed to be suitable for laypersons and healthcare practitioners to use.

For healthcare practitioners, Asst Prof Huang shared that the calculator enables them to calculate their patients’ percentage risk for heart attack in the next 10 years, and the risk scores can be used in treatment algorithms of international cardiac guidelines like the European Society of Cardiology (ESC) from 2021, American College of Cardiology (ACC) from 2019 or the Singapore Lipid guidelines from 2016.

Colour codes to manage different risks

The risk percentage results in the calculator is colour-coded to denote risk category according to the latest international risk classification i.e. ESC classification. If the risk for an individual is from low to moderate for his/her age, the risk percentage will appear in green; if it is high risk or very high risk, the risk percentage will appear in amber or red respectively. 

In the Heart Disease Risk Calculator, individuals can find out how controlling the different risk factors can lead to a reduction in heart disease risk.

In addition, in individuals with significant room for risk improvement, the app will prompt them to click on the risk modification button to see the potential reduction in risk should the risk factors such as LDL (i.e., bad cholesterol) be less well controlled. This would help in facilitating discussions between doctor and patient on the management of risk and benefits. 

Asst Prof Huang added that individuals could also choose to recalculate their risk by lowering the risk factors and levels such as LDL and blood pressure (BP) to specific levels. Alternatively, users can click on the risk modification button to generate an ideal risk score based on LDL or BP in the lowest risk category. The risk factors such as LDL, BP and smoking data can be selected individually to enable individuals to see the change in risk with the control of a single risk factor, or even all selected to show the total reduction in risk with all risk factors being controlled. 

“This calculator not only enables easier risk calculation for healthcare practitioners to facilitate optimising of cardiovascular risk factors, it also empowers the general public with knowledge about their risk, educates them on what they can do to counter the risk, and encourages individuals to take proactive steps to manage their health. This is in line with the Singapore’s Healthier SG initiative to strive for population health and early prevention of chronic disease,” shared Asst Prof Huang.

Check out the video guide from NHCS Youtube below, on using the Heart Disease Risk calculator in Health Buddy!

More usage tips for healthcare practitioners

Should health practitioners opt to use the ESC treatment algorithm, the colours orange and red (corresponding to “high” and “very high” ESC risk categories) suggest that they can preferentially consider lipid-lowering therapies, over non-pharmacological means, in patients with high bad cholesterol (LDL), to aim for LDL levels of 1.8 mmol/l, and 1.4 mmol/l respectively, to better optimise long-term cardiovascular (CV) outcome. This is as recommended in the 2021 ESC guideline to optimise cardiovascular risks for the longer term while balancing the trade-offs such as potential medication side effects and having to be on medication. As mentioned above, the risk percentages can also be applied for use with other medical guidelines.