MI type 1 is an event related to atherosclerotic plaque disruption (eg, rupture, ulceration, erosion) with super- imposed thrombus formation in a coronary artery, resulting in acute reduction in myocardial blood supply and/or distal embolization with subsequent myonecrosis. MI type 2 is myocardial injury caused by conditions other than coronary artery disease that results in an imbalance between myocardial oxygen supply and/or demand (eg, coronary artery embolism or spasm, tachyarrhythmias, anemia, respiratory failure, pro- found hypotension). The measure set developed by our writing committee applies only to MI type 1 and does not uniformly apply to the other 4 types of MI. In fact, some of those measures are even contraindicated with certain MI type, such as aspirin or receptor inhibitor therapies, which are contraindicated in patients with a MI type 2 resulting from severe hemorrhage and anemia. Given the widespread use of very sensitive assays for markers of myocardial necrosis (eg, the highly sensitive and specific cardiac troponin [cTn] biomarkers) and advanced imaging modalities, very small amounts of myonecrosis unre- lated to ischemia can be detected (eg, heart failure, renal fail- ure, myocarditis, pulmonary embolism). Our measures also do not apply to these myocardial injury events, which should be differentiated from true AMI events. For the sake of immediate treatment strategies (eg, reperfu- sion therapy),AMI is differentiated into STEMI and NSTEMI, depending on the existence of ST-segment elevation in 2 contiguous leads on the presenting ECG. Acute STEMI equiv- alent can, however, manifest as: hyperacute T-wave changes, true posterior MI, multilead ST depression with coexistent ST elevation in lead aVR, characteristic diagnostic criteria in the setting of left bundle branch block. The proportion of STEMI versus NSTEMI events varies in different registries and depends on the age of patients, their geographic location, and the type of surveillance used.


The proportion of STEMI versus NSTEMI events varies in different registries and depends on the age of patients, their geographic location, and the type of surveillance used. In general, STEMI patients account for 29% to 47% of all AMI patients.9,10 Updating the existing STEMI/NSTEMI measure set was a priority for the ACC and AHA. Particular attention was given to evidence-based diagnostic and therapeutic strategies that 4 have high impact on outcomes (eg, Class I or III guideline recommendations) of patients with STEMI/NSTEMI and that satisfy the attributes of performance measures (eg, feasible, reliable, actionable). This writing committee developed the measures in this document after comprehensive examination of the most current relevant guidelines, internal discussion and internal voting, peer review, and public comment. 1.2. Disclosure of Relationships With Industry and Other Entities The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that could arise as a result of relationships with industry or other entities (RWI). Detailed information on the ACC/AHA policy on RWI can be found online. All members of the writing committee, as well as those Table 1. 2017 AHA/ACC STEMI and NSTEMI Myocardial Infarction Clinical Performance and Quality Measures No.


2017 AHA/ACC STEMI and NSTEMI Myocardial Infarction Clinical Performance and Quality Measures No. Measure Title Care Setting Attribution Measure Domain Performance Measures PM-1 Aspirin at Arrival Inpatient Facility or Provider Level Effective Clinical Care PM-2 Aspirin Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-3 Beta Blocker Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-4 High-Intensity Statin Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-5 Evaluation of LVEF Inpatient Facility or Provider Level Effective Clinical Care PM-6 ACEI or ARB Prescribed for LVSD Inpatient Facility or Provider Level Effective Clinical Care PM-7 Time to Fibrinolytic Therapy* Inpatient Facility or Provider Level Communication and Care Coordination PM-8 Time to Primary PCI* Inpatient Facility or Provider Level Communication and Care Coordination PM-9 Reperfusion Therapy* Inpatient Facility or Provider Level Effective Clinical Care PM-10 Time From ED Arrival at STEMI Referral Facility to ED Discharge From STEMI Referral Facility in Patients Transferred for Primary PCI* Inpatient Facility Level Communication and Care Coordination PM-11 Time From FMC (At or Before ED Arrival at STEMI Referral Facility) to Primary PCI at STEMI Receiving Facility Among Transferred Patients* Inpatient Facility Level Communication and Care Coordination PM-12 Cardiac Rehabilitation Patient Referral From an Inpatient Setting Inpatient Facility or Provider Level Communication and Care Coordination PM-13 PY12 Receptor Inhibitor Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-14 Immediate Angiography for Resuscitated Out-of-Hospital Cardiac Arrest in STEMI Patients* Inpatient Facility or Provider Level Effective Clinical Care PM-15 Noninvasive Stress Testing Before Discharge in Conservatively Treated Patients Inpatient Facility or Provider Level Efficiency and Cost Reduction PM-16 Early Cardiac Troponin Measurement (Within 6 Hours of Arrival) Inpatient Facility or Provider Level Efficiency and Cost Reduction PM-17 Participation in 1 Regional or National Registries That Include Patients With Acute Myocardial Infarction Registry Inpatient Facility Level Community, Population, and Public Health Quality Measures QM-1 Risk Stratification of NSTEMI Patients With a Risk Score Inpatient Facility or Provider Level Effective Clinical Care QM-2 Early Invasive Strategy (Within 24 Hours) in High-Risk NSTEMI Patients Inpatient Facility or Provider Level Effective Clinical Care QM-3 Therapeutic Hypothermia for Comatose STEMI Patients With Out- of-Hospital Cardiac Arrest* Inpatient Facility or Provider Level Effective Clinical Care QM-4 Aldosterone Antagonist Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care QM-5 Inappropriate In-Hospital Use of NSAIDs Inpatient Facility or Provider Level Patient Safety QM-6 Inappropriate Prescription of Prasugrel at Discharge in Patients With a History of Prior Stroke or TIA Inpatient Facility or Provider Level Patient Safety QM-7 Inappropriate Prescription of High-Dose Aspirin With Ticagrelor at Discharge Inpatient Facility or Provider Level Patient Safety *These measures apply only to patients with STEMI.


These measures apply only to patients with NSTEMI. ACC indicates American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; ED, emergency department; FMC, first medical contact; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; NSAIDs, nonsteroidal anti- inflammatory drugs; NSTEMI, non ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; PM, performance measures; QM, quality measures; STEMI, ST-elevation myocardial infarction; and TIA, transient ischemic attack. 5 selected to serve as peer reviewers of this document, were required to disclose all current relationships and those exist- ing within the 12 months before the initiation of this writing effort. ACC/AHA policy also requires that the writing com- mittee chairs and at least 50% of the writing committee have no relevant RWI. Any writing committee member who develops new RWI during his or her tenure on the writing committee is required to notify staff in writing. These statements are reviewed peri- odically by the Task Force and by members of the writing committee. Author and peer reviewer RWI which are rele- vant to the document are included in the appendixes: Please see Appendix B for relevant writing committee RWI and Appendix C for relevant peer reviewer RWI. Additionally, to ensure complete transparency, the writing committee mem- bers comprehensive disclosure information, including RWI not relevant to the present document, is available online. Disclosure information for the Task Force is also available online. The work of the writing committee was supported exclu- sively by the ACC and the AHA without commercial support. Members of the writing committee volunteered their time for this effort.


Members of the writing committee volunteered their time for this effort. Meetings of the writing committee were confiden- tial and attended only by writing committee members and staff from the ACC, AHA, and the Society for Cardiovascular Angiography and Interventions who served as a collaborator on this project. 2.1. Literature Review In developing the updated STEMI/NSTEMI measure set, the writing committee reviewed evidence-based guidelines and statements that would potentially impact the construct of the measures. The practice guidelines and statements that most directly contributed to the development of these measures are summarized in Table 2. 2.2. Definition and Selection of Measures The writing committee reviewed recent clinical practice guidelines and other clinical guidance documents (Table 2). The writing committee also examined available information on disparities in care to address which new measures might be appropriate as performance versus quality measures for this measure set update. To this effect, an extensive environ- mental scan of the published literature was performed. In a large retrospective analysis of STEMI patients transferred to primary percutaneous coronary intervention (PCI) centers in the ACTION-Get With The Guidelines registry (2007-2010), only 11% had timely door-in-door-out time 30 minutes.20 In another cohort of STEMI patients transferred from non PCI- capable hospitals to STEMI receiving centers (2008-2012), timely primary PCI ( 120 minutes) was achieved in 65% of Another report showed that only 41% of patients were referred to cardiac rehabilitation after AMI.22,23 These reports highlight but a few examples of the persistent disparities in care. Importantly, it appears guideline-directed care can greatly reduce a large proportion of disparities previ- ously noted in women.24,25 All measures were designed to assess quality of care experienced by individuals who have STEMI or NSTEMI in the inpatient setting.


Importantly, it appears guideline-directed care can greatly reduce a large proportion of disparities previ- ously noted in women.24,25 All measures were designed to assess quality of care experienced by individuals who have STEMI or NSTEMI in the inpatient setting. Each measure was designed to limit performance measurement to patients without a valid rea- son for exclusion from the measure. Measure exclusions were those reasons that remove a patient from the denomi- nator, regardless of whether they would be included in the numerator. For example, all measures excluded patients who were <18 years of age, who received comfort care measures only, or in hospice. In contrast to exclusions, denominator exceptions were those conditions that removed a patient from the denominator only if the numerator criteria were not met. Denominator exceptions were used in select cases to allow for a fairer measurement of quality for those providers with higher risk populations. Exceptions were also used to defer to the clinical judgment of the provider. Several of the measures included exceptions. For example, in the case of Inhibitor at Discharge measure, a care provider may write a prescription for an oral P2Y12 receptor inhibi- tor (clopidogrel, ticagrelor, or prasugrel) even if the patient revealed that he/she will not take the medication due to a Table 2. Associated Guidelines and Other Clinical Guidance Documents Clinical Practice Guidelines 1. 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 2. 2013 ACCF/AHA Guideline for the Management of ST-Elevation 3. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular 4. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults14 5.


2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults14 5. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/ AHA Guideline for the Management of ST-Elevation Myocardial 6. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease16 7. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure17 Statements/Performance Measures 1. 2015 ACC/AHA Focused Update of Secondary Prevention Lipid 2. Third Universal Definition of Myocardial Infarction8 3. ACC/AHA 2008 Performance Measures for Adults With ST- Elevation and Non ST-Elevation Myocardial Infarction2 4. ACC/AHA 2008 Statement on Performance Measurement and ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; ESC indicates European Society of Cardiology; HFSA, Heart Failure Society of America; and SCAI, Society for Cardiovascular Angiography and Interventions. 6 number of reasons (eg, concerns about its bleeding risk). In this case, the provider would receive credit for the measure. However, if the patient had explicitly expressed to the pro- vider that he/she did not wish to have the medication pre- scribed, no prescription will be written and the provider can then document in the medical record patient s refusal of the medication. In this scenario, the provider will not be penal- ized for this performance measure because a valid patient reason is documented. The writing committee closely delib- erated the exceptions to be included with each measure and, in some cases, determined not to include any exceptions (as in the case of the patient safety measures).


The writing committee closely delib- erated the exceptions to be included with each measure and, in some cases, determined not to include any exceptions (as in the case of the patient safety measures). During the course of developing the measure set, the writing committee evaluated the potential measures against the ACC/AHA attributes of performance measures (Table 3) to reach consensus on which measures should be advanced for inclusion in the final measure set. After the peer review and public comment period, the writing committee reviewed and discussed the comments received, and further refined the measure set. The writing committee acknowledges that the new measures created in this set will need to be tested and validated over time. By publishing this performance and quality measure set, the writing committee hopes to encourage their widespread and expeditious adoption, as well as facilitate the collection and analysis of data that are needed to continuously assess their relevance over time. In the future, the writing committee members anticipate having data that will allow them to reassess whether any of the mea- sures included in this set should be revised (eg, modified, deleted, or potentially upgraded from a quality measure to a performance measure). 3. AHA/ACC STEMI and NSTEMI Measure Set Performance Measures 3.1. Discussion of Changes to 2008 STEMI and NSTEMI Measure Set After reviewing the existing guidelines, and the 2008 per- formance and quality measure set,2 the writing committee discussed which measures should be revised to reflect the updated science, and worked to identify which guideline rec- ommendations could serve as the basis for new performance or quality measures. The writing committee also reviewed existing measure sets that were publicly available.


The writing committee also reviewed existing measure sets that were publicly available. The following subsections serve as a synopsis of the revi- sions that were made to previous measures, and a description of why the new inpatient measures were created. 3.1.1. Retired Measures The writing committee decided to retire 1 performance mea- sure for smoking cessation counseling because of the consis- tently high levels of performance achieved (Table 4). Other quality measures, previously included as test measures in the 2008 measure set, were retired for the reasons specified in Table 4. 3.1.2. Revised Measures The writing committee reviewed and made changes to 4 mea- sures, which are summarized inTable 5. Most the changes were Table 3. ACC/AHA Task Force on Performance Measures: Attributes for Performance Measures26 1. Evidence Based High-impact area that is useful in improving patient outcomes a) For structural measures, the structure should be closely linked to a meaningful process of care that in turn is linked to a meaningful patient outcome. b) For process measures, the scientific basis for the measure should be well established, and the process should be closely linked to a meaningful patient outcome. c) For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measures based on outcomes should adjust for relevant clinical characteristics through the use of appropriate methodology and high- quality data sources. 2. Measure Selection Measure definition a) The patient group to whom the measure applies (denominator) and the patient group for whom conformance is achieved (numerator) are clearly defined and clinically meaningful. Measure exceptions and exclusions b) Exceptions and exclusions are supported by evidence. Reliability c) The measure is reproducible across organizations and delivery settings. Face validity d) The measure appears to assess what it is intended to.


Face validity d) The measure appears to assess what it is intended to. Content validity e) The measure captures most meaningful aspects of care. Construct validity f) The measure correlates well with other measures of the same aspect of care. 3. Measure Feasibility Reasonable effort and cost a) The data required for the measure can be obtained with reasonable effort and cost. Reasonable time period b) The data required for the measure can be obtained within the period allowed for data collection. Actionable a) Those held accountable can affect the care process or outcome. Unintended consequences avoided b) The likelihood of negative unintended consequences with the measure is low. ACC indicates American College of Cardiology; AHA, American Heart Association. 7 Table 4. Retired STEMI and NSTEMI Measures From the 2008 Set # Care Setting Measure Title Rationale for Retiring the Measure PM-12 Inpatient Adult Smoking Cessation Advice/ Counseling This measure is being retired because perfect scores are consistently achieved and the measure appears to have reached a ceiling effect. Therefore, given absence of room for further improvement, the writing committee opted to omit this measure from the inpatient performance measure set for AMI (realizing also that a separate outpatient CAD measure set will likely address smoking cessation advice/counseling). The writing committee also recognizes the importance of the American Medical Association/Physician Consortium for Performance Improvement Tobacco Use: Screening and Cessation Intervention measure that already exists.27 QM-1 Inpatient LDL Cholesterol Assessment This measure is being retired to be concordant with the new lipid guidelines that no longer recommend LDL measurements to target statin prescription and/or dosing. QM-2 Inpatient Excessive Initial Heparin Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as under-dosing and inappropriate use.


QM-2 Inpatient Excessive Initial Heparin Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as under-dosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-3 Inpatient Excessive Initial Enoxaparin Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-4 Inpatient Excessive Initial Abciximab Dose This measure is being retired because it covers only one aspect of medication use, (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-5 Inpatient Excessive Initial Eptifibatide Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-6 Inpatient Excessive Initial Tirofiban Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability.


In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-7 Inpatient Anticoagulant Dosing Protocol This measure is being retired because it covers only one aspect of medication use and misses other aspects such as inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-8 Inpatient Anticoagulant Error Tracking System This measure is being retired because it covers only limited aspects of medication use and misses other aspects such as inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines. AMI indicates acute myocardial infarction; LDL, low-density lipoprotein; NSTEMI, non ST-elevation myocardial infarction; PM, performance measure; QM, quality measure; and STEMI, ST-elevation myocardial infarction. Table 5. Revised STEMI and NSTEMI Measures # Care Setting Measure Title Rationale for Revision of the Measure PM-4 Inpatient Statin for AMI This measure is being revised to reflect the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults,14 which recommended statin use for all patients with established atherosclerotic cardiovascular disease, including patients with AMI. PM- 5 Inpatient Evaluation of LVEF The title of this measure is being revised from Evaluation of Left Ventricular Systolic Function to Evaluation of Left Ventricular Ejection Fraction. The treatment recommendations regarding the use of guideline-directed medication therapies are based on LVEF, not qualitative estimates of left ventricular systolic function. The 2013 ACCF/AHA STEMI explicitly recommended measuring LVEF. The 2014 AHA/ACC NSTE-ACS guidelines11 likewise have medication recommendations based on knowledge of the ejection fraction.


The 2014 AHA/ACC NSTE-ACS guidelines11 likewise have medication recommendations based on knowledge of the ejection fraction. PM-12 Inpatient Cardiac Rehabilitation Referral This measure is being adapted from the AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services.28 One modification since the publication of that 2010 measurement set was the removal of patient reasons from the list of measure exceptions. Specifically, patient refusal does not constitute a justifiable reason for a clinician not offering a referral to a patient. If documentation in the medical record exists noting that the provider has informed and discussed referral to cardiac rehabilitation/secondary prevention program with the patient, but that the patient refuses a referral, then the healthcare provider would not be expected to send communication about the patient to the cardiac rehabilitation/secondary prevention program. This is consistent with HIPAA confidentiality regulations and shared decision making, and performance would then be considered met by the provider (preventing unjust penalization of the provider). Receptor Inhibitor Prescribed at Discharge In the 2008 ACC/AHA STEMI/NSTEMI measure set,2 a test measure entitled Clopidogrel at Discharge was included. Since then, 2 newer FDA-approved medications ticagrelor and prasugrel have emerged and demonstrated safety, efficacy, and clinical effectiveness after AMI. All 3 medications are inhibitors of the P2Y12 receptor and are recommended in addition to aspirin (as part of a dual antiplatelet regimen) to reduce recurrent ischemic events after AMI. AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; AMI, acute myocardial infarction; FDA, US Food and Drug Administration; HIPAA, the Health Insurance Portability and Accountability Act; LVEF, left ventricular ejection fraction; NSTEMI, non ST-elevation myocardial infarction; NSTE-ACS, non ST-segment elevation acute coronary syndromes; PM, performance measure; and STEMI, ST-elevation myocardial infarction.


AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; AMI, acute myocardial infarction; FDA, US Food and Drug Administration; HIPAA, the Health Insurance Portability and Accountability Act; LVEF, left ventricular ejection fraction; NSTEMI, non ST-elevation myocardial infarction; NSTE-ACS, non ST-segment elevation acute coronary syndromes; PM, performance measure; and STEMI, ST-elevation myocardial infarction. 8 Table 6. New STEMI/NSTEMI Measures No. Care Setting Measure Title Rationale for Creating New Measure Rationale for Designating as a Quality Measure as Opposed to a Performance Measure (If Applicable) PM-14 Inpatient Immediate Angiography for Resuscitated Out- of-Hospital Cardiac Arrest in STEMI Patients This measure seeks to implement a Class I (Level of Evidence B) recommendation in the 2013 ACCF/AHA STEMI guideline12 that immediate angiography with PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI. The writing committee opted to include angiography only, which is easily measurable, and not PCI because of the difficulty associated with ascertaining PCI appropriateness or its lack thereof. Not Applicable PM-15 Inpatient Noninvasive Stress Testing Before Discharge in Conservatively Treated Patients This measure seeks to implement Class I (Level of Evidence B) recommendations in both the guidelines to perform noninvasive stress testing to detect inducible ischemia in medically treated STEMI and NSTEMI patients. Not Applicable PM-16 Inpatient Early Cardiac Troponin Measurement (Within 6 Hours of Arrival) This measure seeks to implement Class I (Level of Evidence A) recommendations in the 2014 AHA/ACC NSTE-ACS guideline11 to measure serial cardiac troponin levels (at presentation and 3 to 6 h after symptom onset in all patients).


Not Applicable PM-16 Inpatient Early Cardiac Troponin Measurement (Within 6 Hours of Arrival) This measure seeks to implement Class I (Level of Evidence A) recommendations in the 2014 AHA/ACC NSTE-ACS guideline11 to measure serial cardiac troponin levels (at presentation and 3 to 6 h after symptom onset in all patients). Not Applicable PM-17 Inpatient Participation in Regional or National Acute Myocardial Infarction Registry This measure seeks to implement Class I (Level of Evidence B) and Class IIa (Level of Evidence B) recommendations in the 2013 STEMI12 AHA/ACC NSTE-ACS guidelines,11 respectively. The writing group felt that participation in a regional or national AMI registry will help track and assess the outcomes, complications, and quality of care for patients with AMI, and is supported by evidence. Not Applicable QM-1 Inpatient Risk Score Stratification for NSTEMI Patients This measure seeks to implement a Class I (Level of Evidence A) recommendation in the 2014 guideline that risk scores should be used to assess prognosis in patients with NSTE-ACS. The writing committee realizes the importance of this measure to dictate the appropriate strategy (invasive versus ischemic- guided) and the timing of the strategy (early versus late invasive) in patients with NSTEMI. The writing committee felt it was best to keep this as a quality measure because of issues related to the measure feasibility. Most registries do not include risk scores, and most risk scores (eg, GRACE, TIMI, PURSUIT) are difficult to compute retrospectively from their respective components, and are likely to cause a significant abstraction burden. QM-2 Inpatient Early Invasive Strategy (Within 24 Hours) in High-Risk NSTEMI Patients This measure seeks to implement a Class I (Level of Evidence A) recommendation in the 2014 AHA/ ACC NSTE-ACS guideline11 that an early invasive strategy should be performed in initially stabilized high-risk patients with NSTE-ACS.


QM-2 Inpatient Early Invasive Strategy (Within 24 Hours) in High-Risk NSTEMI Patients This measure seeks to implement a Class I (Level of Evidence A) recommendation in the 2014 AHA/ ACC NSTE-ACS guideline11 that an early invasive strategy should be performed in initially stabilized high-risk patients with NSTE-ACS. The writing committee felt it was best to keep this as a quality measure for many reasons. The writing group acknowledges that early invasive strategy (compared with a delayed invasive strategy) in high-risk NSTE-ACS patients predominantly reduces recurrent ischemia (rather than the hard outcomes of recurrent MI or death). Although this strategy additionally reduces length of stay and costs, it creates a logistical burden on cardiac catheterization labs, especially during weekends. Finally, objective risk stratification by risk scores is usually not available in current registries; thus, ascertaining which patients benefit from early invasive strategy may not be readily feasible. QM-3 Inpatient Therapeutic Hypothermia for Comatose STEMI Patients With Out- of-Hospital Cardiac Arrest This measure seeks to implement a Class I (Level of Evidence B) recommendation in the 2013 ACCF/AHA STEMI guideline12 that therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of- hospital cardiac arrest caused by VF or VT. The writing committee felt it was best to keep this as a quality measure because of newer controversial data pertinent to the effectiveness, timing, and implementation of therapeutic hypothermia. (Continued) 9 made to reflect the new evidence and updated guideline recom- mendations, to strengthen the measure construct, or to expand the measures to include new proven pharmacotherapies. 3.1.3. New Measures The new measure set includes 4 performance measures and 7 quality measures. Table 6 includes a list of the new measures and their rationale.


Table 6 includes a list of the new measures and their rationale. Four of the quality measures are structured in a typical format in which the goal is to seek a score of 100%. However, 3 of the new quality measures (QM-5, QM-6, and QM-7) are safety measures and, in those, the goal is to seek a score of 0% (eg, 0% use or prescription of an inappropriate treatment reflects an optimal quality of care). For more detailed information on the measure construct, please refer to the detailed measure specifications summarized in Appendix A. 4. Areas for Further Research The writing committee recognizes that the ultimate measure of performance lies in the assessment of outcomes, such as mortality (in-hospital or 30-day), health status, and other outcomes (recurrent MI, urgent repeat revascularization). However, the complexity associated with adjustment for the large number of patient characteristics that both influence treatment decisions and impact mortality make these mea- sures less attractive to use. Thirty-day risk-adjusted AMI mortality has been used by CMS for payment incentives and in public reporting. The impact of these and other measures on hospital quality should be the focus of future research. The committee also realizes that many measures are already topped-out and can be retired to minimize abstraction burden. Additional research should examine the impact of dropping such measures. Furthermore, continuous research to examine temporal trends and disparities (ie, with respect to sex, age, ethnicity) in the achievement of performance and quality measures will help guide future revisions as well as the implementation of the current set.


Furthermore, continuous research to examine temporal trends and disparities (ie, with respect to sex, age, ethnicity) in the achievement of performance and quality measures will help guide future revisions as well as the implementation of the current set. While the majority of current measures are binary (for example, yes or no for medication prescription), the next frontier in performance evaluation may be also to measure doses of prescribed pharmacotherapies and compare them to doses used in ran- domized trials showing benefit. Finally, the ACC ACTION Registry Get With The Guidelines implemented a Defect- Free Care measure for AMI patients, which was endorsed by the National Quality Forum. Our writing committee did not adopt this measure in the current document to avoid the additional burden of data abstraction and reporting. This is QM-4 Inpatient Aldosterone Antagonist at Discharge This measure seeks to implement Class I recommendations in the 2013 ACCF/AHA STEMI12 guidelines supporting the use of aldosterone antagonists in eligible patients with STEMI and NSTEMI, respectively. The writing committee felt it is best to keep this as a quality measure because of issues related to the measure construct. This measure is likely to present a significant abstraction burden and may be relevant only to a small fraction of AMI patients (given the elaborate inclusion/ exclusion criteria in the EPHESUS29 clinical trial). QM-5 Inpatient Inappropriate In- Hospital Use of NSAIDs This measure seeks to implement Class III recommendations (Class III Harm, Level of Evidence: B) in both the 2013 ACCF/AHA guidelines, cautioning against the use of these drugs after AMI. The writing committee felt it is best to keep this as a quality measure given the low impact associated with the use of NSAIDs during the brief hospitalization period (this is likely more relevant in the outpatient setting).


The writing committee felt it is best to keep this as a quality measure given the low impact associated with the use of NSAIDs during the brief hospitalization period (this is likely more relevant in the outpatient setting). The existence of an extensive and evolving list of NSAIDs may also create significant abstraction burden. QM-6 Inpatient Inappropriate Prescription of Prasugrel at Discharge in Patients With a History of Prior Stroke or TIA This measure seeks to implement Class III recommendations (Class III HARM, Level of Evidence: B) in both the 2013 ACCF/AHA STEMI12 guidelines, cautioning against the use of prasugrel in patients with prior TIA/stroke, because of net clinical harm in these patients. The FDA also issued a black box warning on this. The writing committee felt it is best to keep this as a quality measure only for the time being until more data become available pertinent to this measure and its impact in real-world patients. QM-7 Inpatient Inappropriate Prescription of High-Dose Aspirin With Ticagrelor at Discharge This measure seeks to implement Class III recommendations (Class III HARM, Level of Evidence: B) in both the 2013 ACCF/AHA STEMI12 guidelines, cautioning against the use of high-dose aspirin >100 mg among patients receiving ticagrelor. The FDA also issued a black box warning on this. The writing committee felt it is best to keep this as a quality measure only for the time being until more data become available pertinent to this measure and its impact in real-world patients.


The writing committee felt it is best to keep this as a quality measure only for the time being until more data become available pertinent to this measure and its impact in real-world patients. ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EPHESUS, Eplerenone Post Acute Myocardial Infarction Heart Failure Efficacy and Survival Study; FDA, US Food and Drug Administration; GRACE, Global Registry of Acute Coronary Events; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTE- ACS, non ST-segment elevation-acute coronary syndrome; NSTEMI, non ST-elevation myocardial infarction; PM, performance measure; PCI, percutaneous coronary intervention; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin; QM, quality measure; STEMI, ST-segment elevation myocardial infarction; TIA, transient ischemic attack; TIMI, Thrombolysis in Myocardial Infarction; VF, ventricular fibrillation; and VT, ventricular tachycardia. Table 6. Continued No. Care Setting Measure Title Rationale for Creating New Measure Rationale for Designating as a Quality Measure as Opposed to a Performance Measure (If Applicable) 10 especially important given that we have expanded the perfor- mance measure set to include a larger and more comprehen- sive set of 17 performance measures than previously adopted. Our writing committee acknowledges the importance of the Defect-Free Care measure and would like to evaluate its performance and impact in real world before considering it in the future. We also emphasize the importance of assess- ing the impact of compliance (or lack thereof) to some or all performance measures on short- and long-term clinical out- comes. Our writing committee also recognizes that all per- formance measures and quality measures are dynamic and can be revised or retired based on the emergence of scientific evidence and new guideline recommendations.


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Risk of death or reinfarc- tion associated with the use of selective cyclooxygenase-2 inhibitors and nonselective nonsteroidal antiinflammatory drugs after acute myocardial infarction. Circulation. 2006;113:2906 13. 196. Kearney PM, Baigent C, Godwin J, et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ. 2006;332:1302 8. 197. Silverman HS, Pfeifer MP. Relation between use of anti-inflammatory agents and left ventricular free wall rupture during acute myocardial in- farction. Am J Cardiol. 1987;59:363 4. 198. Bulkley BH, Roberts WC. Steroid therapy during acute myocardial in- farction. A cause of delayed healing and of ventricular aneurysm. Am J Med. 1974;56:244 50. KEY WORDS: AHA Scientific Statements acute myocardial infarction non ST-elevation myocardial infarction performance measures quality indicators quality measures ST-elevation myocardial infarction 16 Appendix A. STEMI and NSTEMI Performance Measures Performance Measures for Use in Patients With Inpatient STEMI and NSTEMI Inpatient Measures Short Title: PM-1: Aspirin at Arrival PM-1: AMI: Aspirin Received at Arrival Measure Description: Percentage of patients, age 18 y, hospitalized with AMI who received aspirin within 24 h before or after hospital arrival.


KEY WORDS: AHA Scientific Statements acute myocardial infarction non ST-elevation myocardial infarction performance measures quality indicators quality measures ST-elevation myocardial infarction 16 Appendix A. STEMI and NSTEMI Performance Measures Performance Measures for Use in Patients With Inpatient STEMI and NSTEMI Inpatient Measures Short Title: PM-1: Aspirin at Arrival PM-1: AMI: Aspirin Received at Arrival Measure Description: Percentage of patients, age 18 y, hospitalized with AMI who received aspirin within 24 h before or after hospital arrival. Numerator Patients with AMI who have received aspirin within 24 h before or after hospital arrival Denominator All patients with AMI Denominator Exclusions Patients age <18 y Patients who leave against medical advice on day of or day after arrival Patients who die during hospitalization on day of or day after arrival Patients who are on comfort measures/hospice only documented on day of or day after arrival Patients who are transferred to another hospital for inpatient care on day of or day after arrival Patients received in transfer from the inpatient, outpatient, or ED of another facility Patients discharged on day of or day after arrival Denominator Exceptions Documentation of a medical reason for not prescribing aspirin at arrival (eg, aspirin allergy or intolerance, oral anticoagulant therapy as prearrival medication, active bleeding) Patient currently enrolled in a clinical trial precluding the use of aspirin in its protocol (eg, trials of triple versus dual therapy in atrial fibrillation patients) Measurement Period Encounter Sources of Data Medical record or other database (eg, administrative, clinical, registry) Attribution Measure reportable at the facility or provider level Care Setting Inpatient Rationale Coronary heart disease with atherosclerotic plaque disruption (eg, rupture, erosion, ulceration) and superimposed platelet-rich thrombus formation are the main pathophysiological mechanisms causing MI (type 1 or spontaneous MI).


Numerator Patients with AMI who have received aspirin within 24 h before or after hospital arrival Denominator All patients with AMI Denominator Exclusions Patients age <18 y Patients who leave against medical advice on day of or day after arrival Patients who die during hospitalization on day of or day after arrival Patients who are on comfort measures/hospice only documented on day of or day after arrival Patients who are transferred to another hospital for inpatient care on day of or day after arrival Patients received in transfer from the inpatient, outpatient, or ED of another facility Patients discharged on day of or day after arrival Denominator Exceptions Documentation of a medical reason for not prescribing aspirin at arrival (eg, aspirin allergy or intolerance, oral anticoagulant therapy as prearrival medication, active bleeding) Patient currently enrolled in a clinical trial precluding the use of aspirin in its protocol (eg, trials of triple versus dual therapy in atrial fibrillation patients) Measurement Period Encounter Sources of Data Medical record or other database (eg, administrative, clinical, registry) Attribution Measure reportable at the facility or provider level Care Setting Inpatient Rationale Coronary heart disease with atherosclerotic plaque disruption (eg, rupture, erosion, ulceration) and superimposed platelet-rich thrombus formation are the main pathophysiological mechanisms causing MI (type 1 or spontaneous MI). Acute occlusion of the coronary artery by the plaque + superimposed thrombus complex results in acute imbalance in myocardial oxygen demand and supply which, when prolonged and unabated, leads to myocardial cell necrosis and infarction. Acute and complete occlusion of the coronary artery usually results in STEMI, which usually presents with persistent ST-elevation on the ECG or as an STEMI equivalent (hyperacute T-wave changes, true posterior MI, multilead ST depression with coexistent ST-elevation in lead aVR, characteristic diagnostic criteria in the setting of LBBB).


Acute and complete occlusion of the coronary artery usually results in STEMI, which usually presents with persistent ST-elevation on the ECG or as an STEMI equivalent (hyperacute T-wave changes, true posterior MI, multilead ST depression with coexistent ST-elevation in lead aVR, characteristic diagnostic criteria in the setting of LBBB). On the other hand, severely obstructive but incompletely occlusive coronary lesions usually result in NSTEMI, characterized by the absence of persistent ST elevation on ECG, but rather the presence of ST depression, T-wave inversion or other nonspecific changes. Aspirin inhibits the formation of thromboxane A2, a potent stimulator of platelet aggregation, and is the first-line therapy for AMI.30 A loading dose of 162 to 325 mg of non enteric-coated aspirin formulation should be administered as soon as possible (to be crushed or chewed to achieve rapid absorption), followed preferably by an 81-mg daily dose to minimize bleeding risk.30 34 In the ISIS-2 (Second International Study of Infarct Survival) trial,30 aspirin therapy administered within the first 24 h after acute STEMI resulted in a 23% relative risk reduction in 5-week vascular mortality (or 2.4% absolute risk reduction) in patients with STEMI. Significant reductions in the incidence of non-fatal reinfarction and stroke were also observed with aspirin.30 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Aspirin 162 to 325 mg should be given before primary PCI.33,35,36 (Class I, Level of Evidence: B) 2. Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg loading dose for patients <75 years of age, 75-mg dose for patients >75 years of age) should be administered to patients with STEMI who receive fibrinolytic therapy.30,37,38 (Class I, Level of Evidence: A) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1.


Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg loading dose for patients <75 years of age, 75-mg dose for patients >75 years of age) should be administered to patients with STEMI who receive fibrinolytic therapy.30,37,38 (Class I, Level of Evidence: A) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. Non enteric-coated, chewable aspirin (162 mg to 325 mg) should be given to all patients with NSTE-ACS without contraindications as soon as possible after presentation, and a maintenance dose of aspirin (81 mg/d to 162 mg/d) should be continued indefinitely.7,39 42 (Class I, Level of Evidence: A) 2. Patients not on aspirin therapy should be given non enteric-coated aspirin (325 mg) as soon as possible before PCI.35,36,43,44 (Class I, Level of Evidence: B) 3. In patients with NSTE-ACS who are unable to take aspirin because of hypersensitivity or major gastrointestinal intolerance, a loading dose of clopidogrel followed by a daily maintenance dose should be administered.45 (Class I, Level of Evidence: B) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association, AMI, acute myocardial infarction; ED, emergency department; ISIS-2, Second International Study of Infarct Survival; LBBB, left bundle branch block; MI, myocardial infarction; NSTE-ACS, non ST-elevation acute coronary syndrome; NSTEMI, non ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. 17 Short Title: PM-2: Aspirin at Discharge PM-2: AMI: Aspirin Prescribed at Discharge Measure Description: Percentage of patients, age 18 y, hospitalized with AMI who are prescribed aspirin at hospital discharge.


17 Short Title: PM-2: Aspirin at Discharge PM-2: AMI: Aspirin Prescribed at Discharge Measure Description: Percentage of patients, age 18 y, hospitalized with AMI who are prescribed aspirin at hospital discharge. Numerator Patients with AMI who are prescribed aspirin at hospital discharge Denominator All patients with AMI Denominator Exclusions Patients age <18 y Patients who leave against medical advice Patients who die during hospitalization Patients who are on comfort care measures only or hospice Patients who are transferred to another hospital for inpatient acute care Denominator Exceptions Documentation of a medical reason for not prescribing aspirin at discharge (eg, aspirin allergy or intolerance, oral anticoagulant therapy at discharge, active bleeding) Patient currently enrolled in a clinical trial precluding the use of aspirin in its protocol (eg, trials of triple versus dual therapy in atrial fibrillation patients) Measurement Period Encounter Sources of Data Medical record or other database (eg, administrative, clinical, registry) Attribution Measure reportable at the facility or provider level Care Setting Inpatient Rationale Coronary heart disease with atherosclerotic plaque disruption (eg, rupture, erosion, ulceration) and superimposed platelet-rich thrombus formation are the main pathophysiological mechanisms causing MI (type 1 or spontaneous MI). Acute occlusion of the coronary artery by the plaque + superimposed thrombus complex results in acute imbalance in myocardial oxygen demand and supply which, when prolonged and unabated, leads to myocardial cell necrosis and infarction.