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. 