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Ongoing Cardiometabolic Initiatives

The projects featured below are designed to address barriers in cardiometabolic care by either demonstrating effectiveness of implementation strategies
or scaling strategies to other health systems.

Projects and Publications

For more information about the projects, please reach out to the corresponding author in the publication or to the project contact.

  • HEARTWISE-ASCVD

    Implementation of opportunistic AI-based coronary artery calcium screening

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    Opportunistic screening for ASCVD

    Learn more about the HEARTWISE-ASCVD project

    Project Leads: Fatima Rodriguez, Alex Sandhu

    Aim of Project1

    Evaluate how opportunistic AI-based coronary artery calcium (CAC) screening plus notification affects lipid-lowering
    therapy (LLT) and low-density lipoprotein-cholesterol (LDL-C) levels
    in patients with a positive CAC score, while assessing its
    impact on downstream healthcare utilization patterns.

    Status ONGOING

    The importance of measuring calcified plaque


    • Presence of calcified plaque within arteries is an important signal of cardiovascular disease2
    • Calcified plaque can be identified on chest CT scans obtained for reasons other than to assess cardiac risk2
    • Notifying both patients and clinicians about this risk can motivate shared decision making about LDL-C lowering therapies2

    Methods for Success1

    Prompts & Reminders
    Education
    Audit/Feedback
    Motivation

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    Prompts/Reminders: Notify the clinician and the patient about CAC significance using an image of calcified plaque with
    recommendations for risk discussions, lipid testing, and LDL-C/LLT goals. Follow-up with the clinician and patient at month 2
    if no change.

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    Education: Clinician facilitation and education via evidence-based treatment workflows based on ACC/AHA guidelines, ACC
    Expert consensus pathways and institutional treatment guidelines.

    Audit/Feedback: Provide feedback of LDL-C control via primary care reports

    Motivation: Encourage patients and clinicians to act on results.

    Anticipated Outcomes1

    REACH: Patient eligibility and characteristics
    EFFECTIVENESS: LLT initiation/intensification rates, achievement of target LDL-C <70 mg/dL, quantifiable LDL-C
    reduction at 6 months, changes in healthcare utilization patterns, and lipid testing frequency
    ADOPTION: Clinician response to AI-CAC notifications, lipid panel ordering rates, timely LLT adjustments, and identified
    factors predicting successful notification response
    IMPLEMENTATION: Site level adaptations to notification strategy, modifications to screening program, process evaluations
    will be documented using FRAME-IS framework
    MAINTENANCE: Facilitators, barriers to implement and resources to sustain

    Participation Criteria1

    • >120,000 patients across three health systems
    • Patients with a non-gated chest CT within the previous 2 years, elevated CAC and no established LDL-C control (last LDL-C
      ≥ 70 mg/dL or no LDL-C measurement in last 2 years)
  • PROMPT-Lipid Multicenter Registry Study

    Pragmatic trial of messaging to providers about treatment of HyperLIPIDemia

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    PRagmatic Trial Of Messaging to Providers
    about Treatment of HyperLIPIDemia

    Learn more about the PROMT-LIPID Multicenter Registry
    Study

    Project Lead: Ralph Riella, PharmD, BCPS
    Project contact: ralph.rielloiii@yale.edu

    Aim of Project

    Promote guideline-concordant, high value, quality care for patients with very-high risk atherosclerotic cardiovascular disease (VHR
    ASCVD) by implementing the PROMPT-LIPID Toolkit across eight study sites committed to leveraging computerized decision
    support (CDS) tools.
    Additionally, create a centralized, deidentified data repository of real-world lipid-lowering therapy (LLT)
    treatment
    and low-density lipoprotein cholesterol (LDL-C) monitoring practices for VHR ASCVD patients to facilitate collaborative
    quality improvement efforts amongst health system stakeholders.

    Status ONGOING

    The Importance of User-Designed CDS Tools


    • Clinician input to shape the design of CDS tools is essential for high usability and adoption
    • Targeted, patient-specific EHR alerts can improve intensification of LLT in patients with VHR ASCVD
    • Scaling CDS tools across learning health systems may improve guideline-directed care at a population level

    Methods for Success

    Prompts & Reminders
    Education
    Performance Dashboard

    • Equipping patient’s prescriber with CDS tools (Best Practice Alert + SmartSet) to prompt awareness of evidence-based
      management
      • Intensification of evidence-based LLT among eligible ambulatory patients with VHR ASCVD
      • Ordering of guideline-recommended lab tests for clinical monitoring and follow-up
    • Sharing of best practices, benchmarking, audit/feedback, and other quality improvement strategies through the PROMPT-Lipid
      Multicenter Registry Study Consortium
    • Implementing EHR system embedded ASCVD dashboard to monitor site performance improvement progress at key intervals
      from baseline in real-time

    Anticipated Outcomes

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    LLT intensification at 6 months and 2 years

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    LDL-C goal <70 mg/dL

    LDL-C goal <55 mg/dL

    Participation Criteria

    • Project participation is contingent upon participation in the PROMPT-Lipid Multicenter Registry Study Consortium

    This is a collaborative study between a LATTICE™ Consortium Expert and Amgen.

  • Corrie Lipids

    Examining real-world implementation of the patient-centered Corrie Lipids program

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    Optimizing LDL-C by Improving
    Awareness, Access and Achievement

    Learn more about the Corrie Lipids Program

    Project Leads: Francoise Marvel, MD & Seth Martin, MD, MHS
    Project contact: fmarvel1@jhmi.edu
    Project Fellow: Allison Peng, MD  

    Aim of Project1

    Implement a scalable and evidence-based Corrie Lipids Program (Corrie Health, Inc) to increase low-density lipoprotein
    cholesterol (LDL-C)
    awareness, treatment, and achievement of guideline-directed management.

    Examine real-world implementation of the patient-centered Corrie Lipids Program guided by the implementation science
    framework, RE-AIM (reach, effectiveness, adoption, implementation, maintenance)

    Status ONGOING

    The Importance of Patient Activation for Lipid Optimization


    • When patients understand their lipid disorder, they are more motivated to actively engage in their care2
    • Patient understanding of the importance of LDL-C levels and active participation may increase adherence to LLT3,4,5
    • Supporting accessible lipid testing and app-based reminders can promote patient activation to manage LDL-C levels6

    Methods for Success1

    Patient-facing App
    Clinician-focused Education
    Virtual Coaching
    Guideline-based Lipid Testing

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    Patient-facing app: Embedded clinical decision support with patient education to improve awareness of LDL-C goals along
    with empowering action to adhere to lipid lowering therapies (LLT)

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    Clinician-focused education: Educational training session on cholesterol management defined by AHA/ACC/Multi-society
    Guidelines and ACC Expert Consensus Decision Pathway

    Virtual cholesterol management: Activating patients to know their LDL-C levels and engage in shared decision-making
    about LLT with their clinicians

    Guideline-based LDL-C testing: LDL-C is measured at baseline and repeated in 4-12 weeks if LLT is started or intensified

    Anticipated Outcomes1

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    LDL-C test completion

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    LDL-C attainment at 6 months

    • LDL-C <70 or <55 mg/dL for secondary prevention
    • LDL-C < 100 mg/dL for primary prevention

    Guideline-directed medical therapy (GDMT) LLT use

    Patient activation*

    *Patient activation is the process of actively involving patients in their own healthcare including shared decision-making, self-management, and partnering with HCPs

    Program Eligibility1

    Identifying and engaging clinicians and their high-risk patients who have an indication for LLT intensification to achieve
    recommended LDL-C levels

    1. Know clinical ASCVD1,7

    • CABG
    • PCI
    • PAD
    • CVA

    2. High risk for ASCVD1,7,8

    • Familial hypercholesterolemia
    • LDL-C ≥190 mg/dL
    • Diabetes mellitus
    • ASCVD risk ≥7.5%
    • Subclinical ASCVD

    3. Statin Intolerance1

    • Statin-associated side effects
  • CHA Test to Treat

    Implementation of a large-scale program to identify interventions that could impact patient treatment and adherence to
    guideline-recommended lipid-lowering therapies

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    LDL-C Through Transitions of Care

    Learn more about the CHA Test to Treat Project

    Project Lead: Neha Pagidipati, MD, MPH
    Project contact: lauren.w.cohen@duke.edu

    Aim of Project

    Implementation of a large-scale program to identify interventions that could impact patient treatment and adherence to
    guideline-recommended
    lipid-lowering therapies (LLT). The program gathers data to identify how to improve quality of care
    during hospitalization and through six months
    post-discharge among patients hospitalized for myocardial infraction (MI) or
    percutaneous coronary intervention (PCI).

    Status ONGOING

    The Importance of Continuity of Care


    • Improving the care transition from hospital to home is vital to cardiovascular health.
    • Previous work has shown optimized guideline-directed medical therapy (GDMT), improved care pathways, and coordinated
      education and tools has resulted in an improvement in type 2 diabetes mellitus (T2DM) care. This project aims to build upon
      the success in T2DM and to adapt it to cardiovascular disease (CVD) care.

    Methods for Success

    Prompts & Reminders
    Education
    Care Navigators

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    Inpatient intervention: Increase low-density lipoprotein cholesterol (LDL-C) testing and identification of evidence-based LLT
    as appropriate before discharge

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    Outpatient intervention: Increase repeat LDL-C testing; Identification of evidence-based LLT as appropriate to reach
    recommended LDL-C thresholds (registered nurse remotely coordinates care to help ensure repeat LDL-C
    testing and LLT adherence)

    Anticipated Outcomes

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    Increase LDL-C testing rates

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    Improve GDMT

    Improve outpatient follow-up rates

    Increase achievement of LDL-C recommended levels

    Participation Criteria

    For sites/systems to be eligible for project participation, they must be a member of the CardioHealth Alliance

    This is a LATTICE™ Consortium expert’s independent project that is sponsored by Amgen.

  • CMCA Project

    Determine the effectiveness of holistic, patient-centered, team-based coordinated care for cardiometabolic disease

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    Primary Care Assist

    Learn more about the CMCA Project

    Project Leads: Mikhail Kosiborod, MD and Melissa Magwire, RN MSN, CDCES

    Aim of Project

    Determine the effectiveness of the holistic, patient-centered, team-based care coordinated approach to cardiometabolic disease
    and improve the way care is delivered to this high-risk patient population including patients with ASCVD at four
    key practice settings across the U.S. Advanced practice providers (APPs) and pharmacists (PharmDs) are extenders of care that
    can support the primary care provider (PCP) care for patients.

    Status ONGOING

    The Importance of Primary Care


    • The health and economic burden of cardiometabolic disease impacts patients, clinicians, and healthcare systems.
    • Comprehensive, coordinated care strategies have been shown to improve health outcomes in high-risk patient
      populations, including patients with ASCVD.
    • Expansion of care strategies to patients outside of cardiology clinics, into primary care settings where APPs support
      extension of the physician, can potentially address the totality of cardiometabolic disease and risk reduction on a larger
      scale.

    Methods for Success

    Prompts & Reminders
    Education
    Performance Dashboard

    Equip APPs or PharmDs to champion CMCA protocols and care model embedded within primary care

    Participation Criteria

    Involvement in the Cardiometabolic Center Alliance™

    Anticipated Outcomes

    Demonstrate the effectiveness of a holistic, team-based care model and impact to cardiometabolic metrics:

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    LDL tests ordered

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    LDL tests completed

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    Repeat LDL tests

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    Average LDL trends

    Percent of patients that achieve LDL target

    This is a LATTICE™ Consortium expert’s independent project that is sponsored by Amgen.

  • cvMOBIUS2

    Prospective study leveraging electronic health record system to examine lipid-lowering therapy utilization and LDL-C levels

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    Annual Registry Data Illuminates the State Of
    Care

    Learn more about the cvMOBIUS2 project

    Project Lead: Ann Marie Navar, MD, PhD
    Project Contact: ann.navar@utsouthwestern.edu

    Aim of Project

    Examine and track lipid-lowering therapy (LLT) utilization and low-density lipoprotein cholesterol (LDL-C) levels in adults
    with atherosclerotic cardiovascular disease (ASCVD) seen across a maximum of 25 health systems over 5 years. Annual sub-
    analysis will evaluate factors associated with achievement of appropriate LDL-C lowering in various cohorts of adults with
    ASCVD.

    Status ONGOING

    The Importance of Registry Data


    • LDL-C is one of the key modifiable risk factors for ASCVD
    • Ordering of guideline recommended therapies can reduce LDL-C to target level and reduce cardiovascular risk for patients
      with ASCVD

    Methods for Success

    Performance Dashboard

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    Prospective registry study leveraging Patient-Centered Clinical Research Network (PCORNET) electronic health record
    (EHR) system to examine LLT utilization and LDL-C levels

    Participation Criteria

    For sites/systems to be eligible for project participation, they must utilize the PCORNET EHR system, be willing to provide data,
    and be willing to work with the Duke Clinical Research Institute (DCRI).

    Anticipated Outcomes

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    Increase proportion of patients with ASCVD that are identified and, where appropriate, treated according to ACC/AHA
    guideline recommendations for LLT

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    Understand baseline characteristics of people with established ASCVD who initiate non-statin LLTs versus those who
    don’t initiate non-statin LLTs

    Improve clinical outcomes in adults by LDL-C level at baseline and over time

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    Understand health system heterogeneity of utilization of non-statin LLTs

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    Track lipid trajectories in patients with ASCVD by treatment status

    Recognize novel patterns in LLT uptake

    This is a collaborative study between a LATTICE™ Consortium Expert and Amgen.

  • LOGAN-CV

    Evaluate a multifaceted intervention on clinician knowledge, attitudes, beliefs, and practices for guideline-based medical therapy

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    Performance Platforms for Focused Care

    Learn more about the LOGAN-CV project

    Aim of Project1

    Evaluate the impact of a multifaceted intervention – consisting of a performance dashboard, clinician education modules,
    patient engagement materials, monthly newsletters, and live peer-to-peer discussion calls – on clinician knowledge-
    attitudes-beliefs (KAB) and practices
    as compared to guideline recommendations for adult patients with recent myocardial
    infarction (MI) and low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL on a statin.

    Status COMPLETED

    The Importance of Performance Platforms


    • Clinician education can help overcome clinical inertia and support clinicians in their treatment of patients based on guideline
      recommended lipid-lowering therapies (LLT)2,3
    • Provides availability of clinician-specific, evidence-based metrics for clinicians to view their own patients’ data4,5
    • Real-time assessment of outcomes may provide the opportunity for education on how to improve care for their patients6

    Methods for Success1

    Education
    Performance Dashboard

    Equip clinicians with multifaceted tools to help improve adherence to guideline-based recommendations

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    Education modules and peer-to-peer discussion calls

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    Online performance platform dashboard with a tailored summary of the patients’ lipid management

    Anticipated Outcomes1

    Increase proportion of patients with LDL-C <70 mg/dL achieved at any time during the 12-month intervention (primary)
    Change in:

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    LLT intensification and titration

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    Guideline-aligned LDL-C testing

    Clinicians’ knowledge, attitudes, and beliefs

    Participation Criteria1

    Practices may be eligible to use the Premier Performance Dashboard if they are part of the Premier Network

  • ACC Driving Urgency to Treat LDL-C

    Provide clinicians with tailored messages about guideline-directed medical therapy at the point of care

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    Checking LDL-C Isn’t One and Done

    Learn more about the ACC Driving Urgency Project

    Aim of Project1

    Increase the rate of diagnostic screening of low-density lipoprotein cholesterol (LDL-C) in patients with and
    without ASCVD to improve awareness and implementation of 2018 Guidelines on the Management of Blood
    Cholesterol, and 2022 ACC Expert Consensus Decision Pathway (ECDP) at a national scale.

    Status COMPLETED

    The Importance of Measuring LDL-C


    • LDL-C is a key modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD)2,3
    • If left unchecked, high levels of LDL-C may lead to serious cardiovascular events—like heart attack or stroke4
    • Despite its dangers, there are usually no symptoms of high LDL-C—testing cholesterol levels is the only way of knowing a
      patient’s LDL-C levels5

    Methods for Success1

    Prompts & Reminders
    Education
    Performance Dashboard

    Equip cardiology and primary care clinics to deploy GDMT-related awareness communications and practice/patient-level
    ASCVD dashboards using:

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    Veradigm Practice Fusion EHR system, a cloud-based EHR platform that provides reliable, secure access to information

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    Veradigm TouchPoint Media solution, a tool to reach targeted providers at the point-of-care

    HealthPALS CLINT MAX system, an artificial intelligence platform to analyze patient data and identify actionable care gaps

    Anticipated Outcomes1

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    Clinician engagement (message impressions, click through rates, dashboard sign-up, dashboard usage)

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    Improvements in lipid testing

    Lipid treatment in patients with hypercholesterolemia and ASCVD patients

    Participation Criteria1

    Practice eligibility for project based on:

    • Participation in the network of Veradigm Practice Fusion electronic health record primary care or cardiology practices
    • Treating patients eligible for lipid testing and lipid lowering therapy

    EHR = electronic health record; GDMT = guideline-directed medical therapy

    1. Data on file, Amgen; 2022. 2. Shah NN, et al. American Heart Journal. 2022;253:76-85. 3. Magnussen, et al. N Eng J Med. 2023;389(14):1273-85. 4. American Heart Association. My
    LDL-C Cholesterol Guide. www.heart.org. Accessed August 15, 2025. 5. Heart Disease Risk Factors. www.cdc.gov. Accessed August 15, 2025.

    This is a LATTICE™ Consortium member’s independent project that is sponsored by Amgen.

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Reach us at LATTICEConsortium@amgen.com
to connect with peers and institutions who have
track records in implementation and scaling.

To learn more, watch our American Journal of Managed Care (AJMC) roundtable discussion below, in which experts discuss
real-world learnings and share best practices on how to start, sustain, and scale interventions for cardiovascular care.

Transforming the Management of Cardiovascular Disease at Scale:
Implementation Science in Practice

An American Journal of Managed Care Roundtable (Sponsored by Amgen)

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Up Next:

Leveraging Implementation Science: Impactful Initiatives

10:00
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Coming up:

Securing Stakeholder Support for Implementation Science Initiatives

12:00
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Coming up:

Operationalizing Implementation Science Initiatives

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Coming up:

Scaling and Dissemination of Implementation Science Initiatives

14:36
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Coming up:

Introduction to Implementation Science and LATTICETM Consortium (Video 1)

12:00

Leveraging Implementation Science: Impactful Initiatives

Experts discuss implementation of science-based LATTICE™ initiatives, including LOGAN-CV, Cardiometabolic Center Alliance, and PROMPT-LIPID, and outline the benefits of leveraging EHR systems as a support tool for launching and scaling initiatives.

Securing Stakeholder Support for Implementation Science Initiatives

Experts provide strategies and best practices for engaging important stakeholders within health systems for buy-in on implementation science initiatives.

Operationalizing Implementation Science Initiatives

Our panel discusses methods to ensure the success of implementation science initiatives, including a strong system of measurement, a strategic communication plan, and preparedness to address challenges.

Scaling and Dissemination of Implementation Science Initiatives

Implementation science experts explain approaches for scaling initiatives to more than one health system and discuss the future of LATTICE™ Consortium.

Introduction to Implementation Science and LATTICE™ Consortium

Thought leaders explain implementation science, explain how it can be applied to day-to-day clinical practice, and provide an overview of LATTICE™ Consortium.