Numerator Patients with AMI who are prescribed a high-intensity statin* at hospital discharge *High-intensity statin dose is defined in Table 5 of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults14 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 discharged to hospice or who are on comfort care measures only Patients who are transferred to another acute care hospital Denominator Exceptions Documentation of a medical reason for not prescribing a high-intensity statin (eg, allergy, intolerance or contraindications to high-intensity statin(s), risk of interaction between drugs, or other medical reasons) Documentation of prescription of a moderate-intensity statin for patients >75 y of age Documentation of a patient reason for not prescribing a statin (eg, patient refusal) Patient currently enrolled in a clinical trial related to lipid-lowering therapy 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 Patients with an MI are at high risk for recurrent cardiovascular events. Statins inhibit the HMG-CoA reductase enzyme, the rate-limiting step in cholesterol biosynthesis, and are powerful drugs for lowering LDL-C, with reductions 50% observed with the high-intensity statin regimens. Statins have been shown in multiple secondary prevention trials to reduce cardiovascular events, including coronary heart disease death, recurrent MI, cerebrovascular events, coronary revascularization, and all-cause mortality.50 52 They have also been shown to delay coronary atherosclerosis progression and possibly induce plaque regression, on serial angiographic and intravascular ultrasonographic studies. Given that the clinical evidence does not support the notion of titrating statin therapy to achieve a proposed LDL-C target and that statins are beneficial in all patients at high cardiovascular risk irrespective of their LDL-C levels, the paradigm of treating patients to LDL-C targets is largely abandoned.14,18 On the other hand, high-intensity statin therapy appears to confer incremental clinical benefit compared with less intensive therapy.53 The Cholesterol Treatment Trialists conducted meta-analyses of individual participant data from randomized trials of more versus less intensive statin regimens (5 trials; 39612 patients).53 They demonstrated that more intensive regimens produced a highly significant 15% further reduction in major vascular events, driven by reductions in coronary death or non-fatal MI, coronary revascularization, and ischemic stroke.53 The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommends treatment of patients 75 y of age who have clinical atherosclerotic cardiovascular disease (including those with MI) with high-intensity statin.14 Moderate-intensity statins are recommended in their counterparts >75 y of age and in those who have contraindications/intolerance to high-intensity regimens. The guideline emphasizes that statin therapy should be individualized in persons >75 y of age according to the potential for ASCVD risk-reduction benefits, adverse effects, drug-drug interactions, and patient preferences.14 Improved compliance with therapy is an impetus for timing the initiation of statin therapy before discharge in patients hospitalized with acute MI. Clinical Recommendation(s) The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults14 : 1. High-intensity statin therapy should be initiated or continued as first-line therapy in women and men 75 years of age who have clinical ASCVD, unless contraindicated. (Class I, Level of Evidence: A) 2. In individuals with clinical ASCVD* in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin therapy should be used as the second option if tolerated. (Class I, Level of Evidence: A) 3. In individuals with clinical ASCVD* >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it. (Class IIA; Level of Evidence: B) *Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin. Contraindications, warnings, and precautions are defined for each statin according to the manufacturer s prescribing information.14 ACC indicates American College of Cardiology; ASCVD, atherosclerotic cardiovascular disease; AHA, American Heart Association; AMI, acute myocardial infarction; HMG-CoA, 3-hydroxy-3-methylglutaryl-coenzyme A; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; and TIA, transient ischemic attack. Appendix A. Continued 20 Short Title: PM-5: Evaluation of LVEF PM-5: AMI: Evaluation of LVEF Measure Description: Percentage of patients, age 18 y, hospitalized with AMI, with documentation in the hospital record that LVEF is evaluated during hospitalization or is planned for after discharge. Numerator Patients with AMI with documentation in the hospital record that LVEF assessment, which can be either qualitative or quantitative, is done during the hospitalization or is planned for after 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 None 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 LVEF is important from a therapeutic and prognostic standpoint for patients with acute AMI for many reasons: Patients with reduced LVEF may benefit from specific medical therapies, such as inhibitors of the renin-angiotensin-aldosterone system. The presence of LVSD may help inform and guide the invasive strategy and revascularization modality (eg, further risk stratification in patients with NSTEMI, use of percutaneous circulatory assist devices during percutaneous coronary interventions, choice of surgical revascularization). LVEF is one of the strongest predictors of long-term survival following AMI. LVEF measurement during hospitalization provides a baseline and dictates outpatient reassessment a few weeks later in patients with initially depressed post-MI LVEF. This will help guide the need for device therapy. LV function can be assessed by a variety of modalities (eg, contrast ventriculography, echocardiography, CT angiography). However, a transthoracic echocardiogram is most useful. It is noninvasive, relatively inexpensive, and helps provide a comprehensive assessment of the LV function (regional and global) and size, and rule out post-MI mechanical and other complications. Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. LVEF should be measured in all patients with STEMI. (Class I, Level of Evidence: C) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. A noninvasive imaging test is recommended to evaluate LV function in patients with definite ACS.54 58 (Class I, Level of Evidence: C) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; ACS, acute coronary syndrome; AHA, American Heart Association; AMI, acute myocardial infarction; CT, computed tomography; LV, left ventricular; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; LVSF, left ventricular systolic function, MI, myocardial infarction; NSTEMI, non ST-elevation myocardial infarction; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 21 Short Title: PM-6: ACEI or ARB for LVSD PM-6: AMI: ACEI or ARB Prescribed for LVSD at Discharge Measure Description: Percentage of patients, age 18 y, hospitalized with AMI and LVSD who are prescribed an ACEI or ARB at hospital discharge. Numerator Patients with AMI with LVSD (defined as chart documentation of a LVEF <40% or a narrative description of LVSF consistent with moderate or severe systolic dysfunction) who are prescribed an ACEI or ARB* at hospital discharge *Fixed dose combination medications that contain ACEI or ARB therapy fulfill the numerator criteria if prescribed (eg, the ARNI, sacubitril/valsartan, contains the ARB valsartan and would fulfill the measure criteria if prescribed). Denominator All AMI patients with LVSD 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 care Denominator Exceptions Documentation of medical reasons for not prescribing an ACEI and not prescribing an ARB at discharge (eg, allergy or intolerance to ACEI and ARB including: angioedema, hyperkalemia, hypotension, renal artery stenosis, worsening renal function) 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 ACEIs improve survival in patients with AMI, particularly in those with reduced LVEF. They attenuate LV remodeling and infarct expansion and have a variety of additional beneficial effects (effects on ischemic preconditioning, fibrinolysis, recurrent MI, sudden death). The SAVE (Survival and Ventricular Enlargement) trial demonstrated the benefits of captopril in reducing mortality, recurrent MI and HF hospitalization in AMI patients with an LVEF <40%, but without overt HF on entry.59 Other studies showed comparable findings.60,61 ARBs are reasonable alternatives to ACEIs in patients with AMI and LVSD and can be used for patients who are intolerant to ACEIs. In the VALIANT (Valsartan in Acute Myocardial Infarction) trial, losartan was noninferior to captopril in patients with MI complicated by LVSD, HF, or both.62 Common contraindications to the use of these agents include hypotension, shock, bilateral renal artery stenosis, worsening of renal function with ACEI/ARB exposure, and drug allergy. The ARNI, valsartan/sacubitril, is the first approved ARNI for the treatment of patients with HF and reduced ejection fraction. Compared with the ACEI, enalapril, it reduced the composite endpoint of cardiovascular death or HF hospitalization in the pivotal PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial.17 The ARNI is even recommended as a replacement therapy for symptomatic HF reduced ejection fraction with New York Heart Association class II or III who tolerate an ACEI or ARB.17 An ACEI should not be added to AMI patients already treated with an ARNI given the increased risk of angioedema and other complications (eg, hypotension, renal insufficiency). Additionally, an ARB is already a component of the ARNI regimen and as such, adding ARB is not clinically advocated. Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. An angiotensin-converting enzyme inhibitor (ACE) should be administered within the first 24 hours to all patients with STEMI with anterior location, HF, or ejection fraction (EF) less than or equal to 0.40, unless contraindicated.59,63 65 (Class I, Level of Evidence: A) 2. An angiotensin receptor blocker (ARB) should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors.62,66 (Class I, Level of Evidence: B) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. ACE inhibitors should be started and continued indefinitely in all patients with LVEF <0.40 and in those with hypertension, diabetes mellitus, or stable chronic kidney disease (CKD), unless contraindicated.67,68 (Class I, Level of Evidence: A) 2. ARBs are recommended in patients with HF or MI with LVEF less than 0.40 who are ACE inhibitor intolerant.62,69 (Class I, Level of Evidence: A) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; AMI, acute myocardial infarction; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; HF, heart failure; LV, left ventricular; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; LVSF, left ventricular systolic function; MI; myocardial infarction; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 22 Short Title: PM-7: Door-to-Needle Time PM-7: Acute STEMI: Time to Fibrinolytic Therapy Measure Description: Percentage of patients, age 18 y, with acute STEMI, or its equivalent, who receive fibrinolytic therapy (as the primary reperfusion modality) with a time from hospital arrival to fibrinolysis 30 min. Numerator Patients with acute STEMI (or its equivalent*) defined by characteristic symptoms of myocardial ischemia with diagnostic ST elevation on ECG, whose time from hospital arrival to fibrinolytic therapy (DTN time) is 30 min *Patients with STEMI equivalent on ECG may have: 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. Denominator All patients with acute STEMI and its equivalent Denominator Exclusions Patients age <18 y Patients received in transfer from the inpatient, outpatient, or ED of another facility Denominator Exceptions Documentation of a medical reason for delayed fibrinolytic therapy (eg, cardiopulmonary arrest, initial suspicion of bleeding/stroke or other contraindications to use fibrinolytic therapy, respiratory failure requiring intubation, intra-aortic balloon pump insertion, late presentation >12 h after symptom onset) Documentation of a patient reason (eg, initial patient concern with bleeding hazards) 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 In the ISIS-2 (Second International Study of Infarct Survival) trial,30 the fibrinolytic streptokinase significantly reduced 5-week vascular mortality by 2.8% compared to placebo, which remained significant at a median follow-up of 15 mo. In that trial, the combination of streptokinase and aspirin was also associated with significantly fewer reinfarction, stroke, and death events compared to placebo.30 The benefits of acute reperfusion with fibrinolytic therapy in patients with STEMI was further corroborated by the report from the Fibrinolytic Therapy Trialists, which included nine trials randomizing a total of 58600 patients to fibrinolytic therapy versus control.70 The aforementioned collaborative report also demonstrated an inverse relation between the benefit from fibrinolytic therapy and delay from symptom onset, with highly significant absolute mortality reductions of 3% for patients presenting within 0 to 6 h and 2% for those presenting 7 to 12 h from symptom onset.70 The ACCF/AHA guideline for the management of STEMI12 recommends that patients who present with STEMI to a non PCI-capable hospital should receive timely fibrinolytic therapy, if interhospital timely transfer time for primary PCI is not feasible (to achieve mechanical reperfusion within 120 min of FMC). Despite the lack of strong supporting evidence, the clinical consensus is also to consider fibrinolytic administration in symptomatic STEMI patients presenting >12 h after symptom onset with STEMI when PCI is not feasible and when there is a large myocardium at jeopardy or hemodynamic instability.12 The survival benefit observed with fibrinolytic agents is greatest when they are administered within the first 2 h after the onset of STEMI symptoms.71 73 As the length of time between patient s presentation and the delivery of fibrinolytic therapy (DTN time) increases, the benefit from therapy decreases and progressive increase in infarct size and reduction in LVEF ensue. Thus, the benefit of fibrinolytic therapy is most effective when provided promptly, and the ACCF/AHA guideline set a benchmark time goal from hospital arrival to drug administration, or DTN time, to be 30 min.12 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.70,74,75 (Class I, Level of Evidence: B) 2. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital (Class I, Level of Evidence: B) 3. In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC.30,70,79 83 (Class I, Level of Evidence: A) 4. Fibrinolytic therapy should not be administered to patients with ST depression except when a true posterior (inferobasal) MI is suspected or when associated with ST elevation in lead aVR.70,84 87 (Class III, Level of Evidence: B) 5. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI and cardiogenic shock who are unsuitable candidates for either PCI or CABG.70,88,89 (Class I, Level of Evidence: B) *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible. ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; CABG, coronary artery bypass graft; DTN, door-to-needle; ED, emergency department; FMC, first medical contact; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 23 Short Title: PM-8: First Medical Contact-Device Time PM-8: Acute STEMI: Time to Primary PCI Measure Description: Percentage of patients, age 18 y, with acute STEMI, or its equivalent, who receive primary PCI during the hospital stay with a time from FMC-to-device time 90 min. Numerator Patients with acute STEMI (or its equivalent*) defined by characteristic symptoms of myocardial ischemia with diagnostic ST elevation on ECG, whose FMC-to-device time during primary PCI is 90 min *Patients with STEMI equivalent on ECG may have: 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. Denominator All patients with acute STEMI or its equivalent who receive primary PCI Denominator Exclusions Patients age <18 y Patients received in transfer from the inpatient, outpatient, or ED of another facility Denominator Exceptions Documentation of a medical reason for delayed primary PCI (eg, cardiopulmonary arrest, cardiogenic shock, vascular access or lesion-crossing issues, percutaneous circulatory assist device insertion, respiratory failure requiring intubation, and late presentation >12 h after symptom onset) Patients have received fibrinolytic therapy as the initial reperfusion therapy (eg, nonprimary PCI, rescue PCI) Patient currently enrolled in a clinical trial related to reperfusion therapy 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 Primary PCI has been shown to be superior to fibrinolytic therapy in recanalizing the infarct-related artery and imparts better clinical outcomes.90,91 In a meta- analysis of 23 trials randomizing a total of 7739 patients with acute STEMI to primary angioplasty or fibrinolytic therapy, primary angioplasty was superior in reducing short-term mortality, nonfatal reinfarction, stroke, and the combined cardiovascular endpoint.92 Primary angioplasty also resulted in higher rates of infarct artery patency, TIMI flow, lower rates of recurrent ischemia, emergency repeat revascularization procedures, and intracranial hemorrhage.92 The benefits of primary angioplasty persisted during long-term follow-up and were independent of the type of fibrinolytic therapy used.92 Clinical Recommendation(s) 2013 ACCF/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators.92 94 (Class I, Level of Evidence: A) 2. EMS transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes or less.*95 97 (Class 1, Level of Evidence: B) 3. Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours duration.90 92 (Class I, Level of Evidence: A) *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible. ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; ED, emergency department; EMS, emergency medical services; FMC, first medical contact; LBBB, left bundle branch block; MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; and TIMI, Thrombolysis in Myocardial Infarction. Appendix A. Continued 24 Short Title: PM-9: Reperfusion Therapy PM-9: Acute STEMI: Reperfusion Therapy Measure Description: Percentage of patients, age 18 y, with acute STEMI, or its equivalent, who receive fibrinolytic therapy or primary PCI. Numerator Patients with acute STEMI (or its equivalent*) defined by characteristic symptoms of myocardial ischemia with diagnostic ST elevation on ECG, who receive fibrinolytic therapy or primary PCI *Patients with STEMI equivalent on ECG may have: 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. Denominator All patients with acute STEMI and its equivalent Denominator Exclusions Patients age <18 y Patients who leave against medical advice shortly/immediately after arrival Patients who are on comfort care measures only or hospice documented on arrival Denominator Exceptions Documentation of a medical reason for not receiving reperfusion therapy (eg, active major bleeding, acute stroke, terminal illness/ futile culprit artery too small, no identifiable culprit or spontaneous reperfusion of the infarct artery without an obstructive lesion, severe CAD necessitating urgent/emergency CABG, attempted but unsuccessful PCI, late presentation >12 h after symptom onset) 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 Overall, patients presenting with acute STEMI can undergo either pharmacologic (fibrinolytic therapy) or mechanical (primary angioplasty/PCI) reperfusion. Given its superiority to fibrinolytic therapy, the ACCF/AHA guideline for the management of STEMI12 outlines that primary PCI is the preferred treatment and should be performed timely in patients with acute STEMI. However, if primary PCI cannot be performed in a timely manner (within FMC-to-device time] 90 min, including the inability to transfer the patient timely from a non PCI-capable to a PCI-capable hospital to achieve FMC-to-device time 120 min), timely fibrinolytic therapy (within DTN 30 min) is an acceptable alternative therapeutic strategy. On the other hand, if fibrinolytic therapy is contraindicated or if the complications of cardiogenic shock or acute severe heart failure ensue, primary PCI should be undertaken irrespective of the time delay from FMC or STEMI symptom onset. Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours.70,92 (Class I, Level of Evidence: A) 2. Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators.92 94 (Class I, Level of Evidence: A) 3. EMS transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes or less.*95 97 (Class I, Level of Evidence: B) 4. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less.*93,94,98,99 (Class I, Level of Evidence: B) 5. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.70,74,75 (Class I, Level of Evidence: B) 6. Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours duration.90 92 (Class I, Level of Evidence: A) 7. Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from FMC.100,101 (Class I, Level of Evidence: B) 8. Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from MI onset.102 105 (Class I, Level of Evidence: B) 9. In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC.30,70,79 83 (Class I, Level of Evidence: A) *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible. ACCF indicates American College of Cardiology Foundation; AHA American Heart Association; CABG, coronary artery bypass graft; CAD, coronary artery disease; DTN, door-to-needle; EMS, emergency medical services; FMC, first medical contact; HF, heart failure; LBBB, left bundle branch block; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 25 Short Title: PM-10: Door-in-Door-Out Time PM-10: Acute STEMI: Time From ED Arrival at STEMI Referral Facility to ED Discharge From STEMI Referral Facility in Patients Transferred for Primary PCI Measure Description: Percentage of patients, age 18 y, with acute STEMI, or its equivalent, whose median time from the ED arrival at STEMI referral facility to ED discharge from STEMI referral facility is 30 min. Numerator Patients with acute STEMI (or its equivalent*) defined by characteristic symptoms of myocardial ischemia with diagnostic ST elevation on ECG, who are seen initially at a non PCI-capable hospital and who are transferred to a PCI-capable hospital within DIDO time 30 min *Patients with STEMI equivalent on ECG may have: 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. Denominator All patients with acute STEMI, or its equivalent, who are seen initially at a non PCI-capable hospital and who are transferred to a PCI-capable hospital Denominator Exclusions Patients age <18 y Patients who are transferred for a PCI that is described as nonprimary treatment for AMI by a healthcare provider (eg, patients who receive fibrinolytic therapy as the primary reperfusion therapy) Denominator Exceptions Documentation of a medical reason for the delay (eg, cardiopulmonary arrest, balloon pump insertion, respiratory failure requiring intubation) Documentation of a patient reason for the delay (eg, initial concern, patient choice) Patient currently enrolled in a clinical trial related to AMI and reperfusion therapy Measurement Period Encounter Sources of Data Medical record or other database (eg, administrative, clinical, registry) Attribution Measure reportable at the facility level Only STEMI referral facility (non PCI-capable facility) is accountable for this measure. Care Setting Inpatient Rationale Clinical trials have demonstrated improved outcome for patients with STEMI who are transferred to a primary PCI hospital in a timely manner. Current guidelines recommend that transfer occur immediately with an overall goal of FMC-to-device time of 120 min; this can be best achieved by shortening the time in the first ED and transferring the STEMI patient within DIDO of 30 min.20,98,99,106 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less.*93,94,98,99 (Class I, Level of Evidence: B) 2. Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset.107 (Class I, Level of Evidence: B) *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible. ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; AMI, acute myocardial infarction; CABG, coronary artery bypass graft; DIDO, door-in-door-out; ED, emergency department; FMC, first medical contact; LBBB; left bundle branch block; MI, myocardial infarction; LOE; level of evidence; PCI, percutaneous coronary intervention; and STEMI, ST- elevation myocardial infarction. Appendix A. Continued 26 Short Title: PM-11: Time to Primary PCI Among Transferred Patients PM-11: Acute STEMI: Time From FMC (at or Before ED Arrival at STEMI Referral Facility) to Primary PCI at STEMI Receiving Facility Among Transferred Patients Measure Description: Percentage of patients, age 18 y, with acute STEMI, or its equivalent, whose median time from FMC (at or before ED arrival to the STEMI referral facility [eg, non PCI-capable facility]) to primary PCI at the STEMI receiving facility (PCI-capable facility) is 120 min. Numerator Patients with acute STEMI (or its equivalent*) defined by characteristic symptoms of myocardial ischemia with diagnostic ST elevation on ECG, who are transferred to a PCI-capable hospital and have received primary PCI 120 min from FMC *Patients with STEMI equivalent on ECG may have: 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. Denominator All patients with acute STEMI, or its equivalent, who are seen initially at non PCI-capable hospital and who are transferred to a PCI-capable hospital and have received primary PCI Denominator Exclusions Patients age <18 y Patients who are transferred for a PCI that is described as nonprimary by a healthcare provider (eg, patients who receive fibrinolytic therapy at the referral facility as the primary reperfusion therapy) Denominator Exceptions Documentation of a medical reason for the delay (eg, cardiopulmonary arrest, balloon pump insertion, respiratory failure requiring intubation) Documentation of a patient reason for the delay (eg, initial patient concern) Patient currently enrolled in a clinical trial related to STEMI and reperfusion therapy Measurement Period Encounter Sources of Data Medical record or other database (eg, administrative, clinical, registry) Attribution Measure reportable at the facility* level *Both STEMI referral facility (non PCI-capable) and STEMI receiving facility (PCI-capable) are accountable for this measure. Care Setting Inpatient Rationale Patient outcome is improved if patients, initially presenting to a non PCI-capable hospital, can be quickly transferred to a PCI-capable hospital for Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less.*93,94,98,99 (Class I, Level of Evidence: B) *The proposed time windows are system goals. For any individual patient, every effort should be made to provide reperfusion therapy as rapidly as possible. ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; ED, emergency department; FMC, first medical contact; LBBB; left bundle branch block; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 27 Short Title: PM-12: Cardiac Rehabilitation Referral PM-12: AMI: CR Patient Referral From an Inpatient Setting Measure Description: Percentage of patients, age 18 y, hospitalized with AMI who are referred to an outpatient CR/secondary prevention program during their AMI hospital stay. Numerator AMI patients who are referred to outpatient CR/secondary prevention program prior to hospital discharge Denominator Number of hospitalized patients in the reporting period hospitalized with qualifying event/diagnosis Denominator Exclusions None Denominator Exceptions Provider-oriented criteria (patient deemed to have a high-risk condition or a contraindication to exercise, for example) Healthcare system barriers (eg, financial barriers or lack of CR programs near a patient s home) 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 A key component to outpatient CR program utilization is the appropriate and timely referral of patients. Generally, the most important time for this referral to take place is while the patient is hospitalized for a qualifying event/diagnosis (eg, MI, chronic stable angina, CABG, PCI, cardiac valve surgery, or cardiac transplantation). This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize the appropriate referral of a patient to an outpatient CR program. This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve disease states or other conditions for which CR services have been found to be appropriate and beneficial (eg, following MI, CABG surgery). This performance measure is provided in a format that is meant to allow easy and flexible inclusion into such performance measurement sets. Effective referral of appropriate inpatients to an outpatient CR program is the responsibility of the healthcare team within a healthcare system that is primarily responsible for providing cardiovascular care to the patient during the hospitalization. Clinical Recommendation(s) ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery108 1. Cardiac rehabilitation should be offered to all eligible patients after CABG. (Class I, Level of Evidence: B). ACC/AHA 2007 Update of the Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction109 1. Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (eg, recent acute coronary syndrome or revascularization, HF) is recommended (Class I, Level of Evidence: B). ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina and Non ST-Segment Elevation Myocardial Infarction110 1. Cardiac rehabilitation/secondary prevention programs are recommended for patients with UA/NSTEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is particularly warranted. (Class I, Level of Evidence: B) 2. Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with UA/NSTEMI, particularly those with multiple modifiable risk factors and those moderate- to high-risk patients in whom supervised or monitored exercise training is warranted. (Class I, Level of Evidence: B) ACC/AHA 2007 Chronic Angina Focused Update of the Guidelines for the Management of Patients With Chronic Stable Angina111 1. Medically supervised programs (cardiac rehabilitation) are recommended for at-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure). (Class I, Level of Evidence: B) ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult112 1. Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of HF and reduced LVEF. (Class I, Level of Evidence: B) AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update113 1. A comprehensive risk-reduction regimen, such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program, should be recommended to women with a recent acute coronary syndrome or coronary intervention, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease (Class I, Level of Evidence: A), or current/prior symptoms of heart failure and an LVEF 40%. (Class I, Level of Evidence: B) ACC/AHA/SCAI 2007 Focused Update of the Guidelines for Percutaneous Coronary Intervention114 1. Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure) is recommended. (Class I, Level of Evidence: B) ACC indicates American College of Cardiology; AHA, American Heart Association; AMI, acute myocardial infarction; CABG, coronary artery bypass graft; CR, cardiac rehabilitation; LVEF, left ventricular ejection fraction; MI, myocardial infarction; PCI, percutaneous coronary intervention; SCAI, the Society for Cardiac Angiography and Interventions; and UA/NSTEMI, unstable angina/non ST-segment elevation myocardial infarction. Appendix A. Continued 28 Inhibitor at Discharge Receptor Inhibitor Prescribed at Discharge Measure description: Percentage of patients, age 18 y, hospitalized with AMI who are prescribed an appropriate P2Y12 receptor inhibitor at hospital discharge. Numerator Patients with AMI who are prescribed an appropriate P2Y12 receptor inhibitor at hospital discharge receptor inhibitors include: Clopidogrel, prasugrel, or ticagrelor in PCI-treated patients Clopidogrel or ticagrelor in medically treated patients Clopidogrel or prasugrel in STEMI patients receiving fibrinolytic therapy 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 a P2Y12 receptor inhibitor at hospital discharge (eg, allergy or intolerance to each of the three P2Y12 receptor inhibitors, oral anticoagulant therapy at discharge, active bleeding, patients with planned CABG procedure done after discharge) Documentation of a patient reason for not prescribing a P2Y12 receptor inhibitor at hospital discharge Patient currently enrolled in a clinical trial related to AMI and involving new antiplatelet therapies 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). Dual antiplatelet therapy has become the mainstay treatment strategy after AMI. Aspirin inhibits the formation of thromboxane A2, a potent stimulator of platelet aggregation, and is the first-line therapy for AMI. P2Y12 receptor inhibitors have incremental benefits to aspirin, and patients with acute MI who are treated with P2Y12 receptor inhibitor at discharge have improved cardiovascular outcomes (predominantly, lower recurrent MI events).11,12 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (bare-metal or drug-eluting) during primary PCI using the following maintenance doses: a. Clopidogrel 75 mg daily115,116 (Class I, Level of Evidence: B); or b. Prasugrel 10 mg daily115 (Class I, Level of Evidence: B); or c. Ticagrelor 90 mg twice a day*117 (Class I, Level of Evidence: B) *The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily. 2. Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack.116 (Class III, Level of Evidence: B) 3. Aspirin should be continued indefinitely30,37,38 (Class I, Level of Evidence: A) and clopidogrel (75 mg daily) should be continued for at least 14 days30,37,38 (Class I, Level of Evidence: A) and up to 1 year (Class I, Level of Evidence: C) in patients with STEMI who receive fibrinolytic therapy. 4. Clopidogrel should be provided as follows: a. A 300-mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI within 24 hours of receiving fibrinolytic therapy (Class I, Level of Evidence: C); b. A 600-mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI more than 24 hours after receiving fibrinolytic therapy (Class I, Level of Evidence: C); and c. A dose of 75 mg daily should be given after PCI.37,38,116,117 (Class I, Level of Evidence: C) (Continued) Appendix A. Continued 29 Appendix A. Continued Clinical Recommendation(s) Continued 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 inhibitor (either clopidogrel or ticagrelor) in addition to aspirin should be administered for up to 12 months to all patients with NSTE-ACS without contraindications who are treated with either an early invasive or ischemia-guided strategy. Options include: Clopidogrel: 300-mg or 600-mg loading dose, then 75 mg daily.33,42 (Class I, Level of Evidence: B) Ticagrelor: 180-mg loading dose, then 90 mg twice daily.7,118 (Class I, Level of Evidence: B) 2. In patients receiving a stent (bare-metal stent or drug-eluting stent [DES]) during PCI for NSTE-ACS, P2Y12 inhibitor therapy should be given for at least Options include: (Class I, Level of Evidence: B) or (Class I, Level of Evidence: B) or Ticagrelor: 90 mg twice daily7 (Class I, Level of Evidence: B) 3. In addition to aspirin, a P2Y12 inhibitor (either clopidogrel or ticagrelor) should be continued for up to 12 months in all patients with NSTE-ACS without contraindications who are treated with an ischemia-guided strategy. Options include: (Class I, Level of Evidence: B) or Ticagrelor: 90 mg twice daily7,118 (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; CABG, coronary artery bypass graft; MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; and NSTE-ACS, non ST-elevation acute coronary syndrome. 30 Short Title: PM-14: Immediate Angiography After Cardiac Arrest PM-14: STEMI: Immediate Angiography for Resuscitated Out-of-Hospital Cardiac Arrest in STEMI Patients Measure Description: Percentage of patients, age 18 y, who are resuscitated from out-of-hospital cardiac arrest and whose initial ECG shows STEMI, who receive immediate angiography. Numerator Patients with acute STEMI (or its equivalent*) defined by characteristic symptoms of myocardial ischemia with diagnostic ST elevation on ECG, who are resuscitated from out-of-hospital cardiac arrest and receive immediate angiography *Patients with STEMI equivalent on ECG may have: 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 Note: Immediate angiography is defined as invasive angiography within 120 min after resuscitation from out-of-hospital cardiac arrest. Denominator All patients with STEMI who are resuscitated from out-of-hospital cardiac arrest Denominator Exclusions Patients age <18 y Patients who die during hospitalization shortly following their out-of-hospital cardiac arrest (<120 min) Patients who are transferred to hospice or are placed on comfort care measures shortly after their out-of-hospital cardiac arrest (<120 min) Patients received in transfer from another facility Denominator Exceptions Documentation of a medical reason for not receiving immediate angiography after resuscitated out-of-hospital cardiac arrest (eg, contraindications to invasive angiography, terminal illness/futile medical condition) Documentation of a patient reason for not receiving immediate angiography after resuscitated out-of-hospital cardiac arrest (eg, patient s will or family wishes) Documentation of a system reason for not receiving immediate angiography after resuscitated out-of-hospital cardiac arrest (eg, presentation to a non PCI capable hospital and too unstable to transfer) 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 Many patients with cardiac arrest and ST elevation on the ECG often have high-risk coronary anatomy, which may benefit from timely coronary angiography to identify severe coronary artery disease and possibly guide/dictate revascularization (usually with PCI).12,122 137 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Immediate angiography and PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows (Class I, Level of Evidence: B) ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; LBBB; left bundle branch block; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 31 Short Title: PM-15: Stress Test in Conservatively Treated Patients PM-15: AMI: Non-Invasive Stress Testing Before Discharge in Conservatively Treated Patients Measure Description: Percentage of patients, age 18 y, hospitalized with AMI, who are initially conservatively managed (have not received invasive coronary angiography) and with documentation in the hospital record that a noninvasive stress testing was performed before discharge. Numerator Patients with AMI who are initially conservatively managed and who received a noninvasive stress test prior to discharge Denominator All patients with AMI who are initially treated with a conservative management strategy (medical therapies alone without invasive coronary angiography as a planned initial therapy) 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 receiving a noninvasive stress test before discharge (eg, contraindications to noninvasive stress testing [for instance, patients with intolerance to dobutamine or vasodilator, or patients with ongoing ischemia], terminal illness/futile, not candidate for invasive strategy or revascularization) Documentation of a patient reason for not receiving a noninvasive stress test before discharge (eg, patient choice not to undergo ischemic work-up or to postpone to the outpatient setting) Documentation of cross-over from an initial conservative management to undergo invasive coronary angiography without the need for a noninvasive stress test (as in the case of recurrent spontaneous ischemia) 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 Some patients with AMI who are managed conservatively (eg, managed with medical therapies, with coronary angiography not planned as an initial treatment strategy) have high-risk coronary artery disease. These patients may not experience spontaneous ischemia during their hospitalization and need to be further risk stratified before discharge with a stress test (preferably, a submaximal stress test). This will help identify the high-risk patient who needs invasive angiography and possible revascularization, predominantly to mitigate recurrent ischemia/MI.11,12,138 141 A noninvasive stress test can be exercise-based or pharmacological, and the means for detecting ischemia may be via ECG alone or with an added imaging modality. Notably, many patients with AMI who are managed conservatively initially may cross over to undergo invasive coronary angiography, without undergoing a noninvasive stress test. Common clinical indications for resorting to coronary angiography during the same AMI hospitalization after an initial conservative management trial include, but are not limited to: spontaneous non-inducible ischemia among patients already treated with aggressive medical therapies; LVSD, where a high level of suspicion for left main or multi-vessel coronary artery disease exists. These aforementioned scenarios are to be differentiated (and excluded from the denominator) from those during which coronary angiography is performed in initially conservatively managed AMI patients because of a high-risk noninvasive stress test. Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Noninvasive testing for ischemia should be performed before discharge to assess the presence and extent of inducible ischemia in patients with STEMI who have not had coronary angiography and do not have high-risk clinical features for which coronary angiography would be warranted.138,140,141 (Class I, Level of Evidence: B) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. Noninvasive stress testing is recommended in low- and intermediate-risk patients who have been free of ischemia at rest or with low-level activity for a (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; LVSD, left ventricular systolic dysfunction; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 32 Short Title: PM-16: Early Troponin Measurement After NSTEMI PM-16: Acute NSTEMI: Early Cardiac Troponin Measurement (Within 6 Hours of Arrival) Measure Description: Percentage of patients, age 18 y, hospitalized with acute NSTEMI, who have cardiac troponin biomarkers measured within 6 h of hospital arrival. Numerator Patients with acute NSTEMI who have at least 1 set of cardiac troponin biomarkers, measured by central laboratory troponin assays and excluding point-of-care assays in the ED or elsewhere, within 6 h of hospital arrival Denominator All patients with acute NSTEMI Denominator Exclusions Patients age <18 y Patients who leave against medical advice shortly after arrival (<6 h) Patients who die during hospitalization shortly after arrival (<6 h) Patients who are on comfort measures/hospice only documented shortly after arrival (<6 h) Patients who are transferred to another hospital for inpatient care shortly after arrival (<6 h) Patients received in transfer from the inpatient, outpatient, or ED of another facility Patients discharged shortly after arrival (<6 h) Denominator Exceptions None 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 Troponins are components of the myocardial cell contractile apparatus. When measured in the circulation, they are very sensitive and specific to diagnose myocardial necrosis. In the correct clinical setting (eg, angina/ischemic symptoms, ischemic changes on the ECG, imaging evidence of ischemia), a pattern of rise and fall in troponin I or T levels is essential to the diagnosis of AMI. Although STEMI is usually readily diagnosed by the presence of acute current of injury on the presenting ECG, patients with NSTE-ACS can present with nonspecific changes on the ECG (eg, subtle or nonspecific ST or T wave changes). Thus, measuring troponin levels expeditiously help in the early diagnosis and risk stratification of these patients, which can lead to earlier triage and institution of appropriate medical and interventional treatments.11 Clinical Recommendation(s) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. Serial cardiac troponin I or T levels (when a contemporary assay is used) should be obtained at presentation and 3 to 6 hours after symptom onset in all patients who present with symptoms consistent with ACS to identify a rising and/or falling pattern of values.8,142 147 (Class I, Level of Evidence: A) 2. Additional troponin levels should be obtained beyond 6 hours after symptom onset in patients with normal troponin levels on serial examination when changes on ECG and/or clinical presentation confer an intermediate or high index of suspicion for ACS.8,148 150 (Class I, Level of Evidence: A) 3. If the time of symptom onset is ambiguous, the time of presentation should be considered the time of onset for assessing troponin values.143,145,150 (Class I, Level of Evidence: A) ACC indicates American College of Cardiology; ACS; acute coronary syndrome; AHA, American Heart Association; AMI, acute myocardial infarction; ED, emergency department; NSTE-ACS, non ST-elevation acute coronary syndrome; NSTEMI, non ST-elevation myocardial infarction; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 33 Short Title: PM-17: AMI Registry Participation PM-17: AMI: Participation in 1 Regional or National Registries That Include Patients With Acute Myocardial Infarction Measure Description: Participation in a national or regional AMI registry that provides regular performance reports based on benchmarked data. Numerator Does the facility participate in a national or regional AMI registry* that provides regular performance reports based on benchmarked data? (yes/no) *Examples of such registries include the NCDR ACTION Registry-Get With The Guidelines, Mission Lifeline, and the D2B Alliance. Denominator Not applicable Denominator Exclusions None Denominator Exceptions None Measurement Period Not applicable Sources of Data Facility attestation Attribution Measure reportable at the facility level only Care Setting Inpatient Rationale Participation in registries allows tracking of quality of care and benchmarking against best practices.12 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B (Class I, Level of Evidence: B) 2014 AHA/ACC Guideline for the Management of Patients With Non St-Elevation Acute Coronary Syndromes11 1. Participation in a standardized quality-of-care data registry designed to track and measure outcomes, complications, and performance measures can be beneficial in improving the quality of NSTE-ACS care.2,152,154 160 (Class IIa, Level of Evidence: B) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; AMI acute myocardial infarction; D2B, Door-to-Balloon; NCDR, National Cardiovascular Data Registry; NSTE-ACS, non ST-elevation acute coronary syndrome; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 34 Quality Improvement Measures for Inpatient STEMI and NSTEMI Patients Inpatient Measures Short Title: QM-1: Risk Score Stratification for NSTEMI QM-1: NSTEMI: Risk Stratification of NSTEMI Patients With a Risk Score Measure Description: Percentage of patients, age 18 y, hospitalized with NSTEMI, who have a risk stratification score documented during hospitalization. Numerator Patients with NSTEMI who have a risk score documented during hospitalization Examples of commonly utilized risk stratification scores include: TIMI risk score GRACE risk score Denominator All patients with NSTEMI 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 None 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 Objective risk stratification with validated risk scores help triage and dictate the initial treatment strategy in patients with NSTEMI. For example, those at high-risk will likely benefit from an early invasive strategy (within 12 to 24 h), while intermediate-risk patients may receive delayed invasive strategy (within 24 to 72 h). In addition, risk scores, such as the TIMI risk index and GRACE risk model are useful in predicting recurrent cardiovascular outcomes (short- and intermediate-term) following NSTEMI.11,161,162 Clinical Recommendation(s) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. Risk scores should be used to assess prognosis in patients with NSTE-ACS.161,163 170 (Class I, Level of Evidence: A) ACC indicates American College of Cardiology; AHA, American Heart Association; GRACE, Global Registry of Acute Coronary Events; NSTE-ACS, non ST-elevation acute coronary syndrome; NSTEMI, non ST-elevation myocardial infarction; and TIMI, Thrombolysis in Myocardial Infarction. Appendix A. Continued 35 Short Title: QM-2: Early Invasive Strategy for High-Risk NSTEMI QM-2: Acute NSTEMI: Early Invasive Strategy (Within <24 Hours) for High-Risk NSTEMI Patients Measure Description: Percentage of patients, age 18 y, hospitalized with acute NSTEMI, who are at high risk and who receive an early invasive strategy within 24 h of admission. Numerator Patients with acute NSTEMI who are high risk* and receive early invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) within 24 h of admission *A high-risk NSTEMI patient is best defined by an objective risk score (eg, GRACE risk score >140 or TIMI risk score >4). Denominator All patients with acute NSTEMI who are at high risk Denominator Exclusions Patients age <18 y Patients who leave against medical advice on day of or day after arrival Patients who die early during hospitalization on day of or day after arrival Patients who are on comfort care measures only or hospice 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 discharged on day of or day after arrival Patients received in transfer from the inpatient, outpatient, or ED of another facility Patients who are unstable (refractory angina/ischemia, new or worsening heart failure, mitral regurgitation, hemodynamic instability, sustained ventricular fibrillation or pulseless ventricular tachycardia), need urgent/immediate invasive strategy within 2 h, and are excluded from denominator and numerator Denominator Exceptions Documentation of a medical reason for not receiving an early invasive strategy after high-risk NSTEMI (eg, extensive clinical comorbidities, contraindications to invasive angiography, terminal illness/futile) Documentation of a patient reason for not receiving an early invasive strategy after high-risk NSTEMI Documentation of a system reason for not receiving an early invasive strategy after high-risk NSTEMI (eg, financial barriers, hospitalization at a facility without a cardiac catheterization laboratory) 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 have concluded that a strategy of routine invasive therapy is generally superior to an ischemia-guided strategy or a selectively invasive approach. Compared with a delayed invasive strategy (within 24 to 72 h), an early invasive strategy (within the initial 24 h) in patients with NSTEMI reduces recurrent/refractory ischemia, length of stay, and costs. However, there is no definitive evidence that it has an incremental benefit in reducing MI or death. Patients who are unstable (refractory angina/ischemia, new or worsening heart failure, mitral regurgitation, hemodynamic instability, sustained ventricular fibrillation or ventricular tachycardia) need an urgent/immediate invasive strategy within 2 h, and are excluded from the denominator and numerator. Clinical Recommendation(s) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. An early invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTE- ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (Table 8).161,163,179 183 (Class I, Level of Evidence: B) 2. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not recommended in patients with: a. (eg, hepatic, renal, pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Class III, Level of Evidence: C) b. Acute chest pain and a low likelihood of ACS (Class III, Level of Evidence: B) who are troponin-negative, especially women.178 (Class: III, Level of Evidence: C) 3. Older patients with NSTE-ACS should be treated with GDMT, an early invasive strategy, and revascularization as appropriate.184 188 (Class I, Level of Evidence: A) 4. Patients with prior CABG and NSTE-ACS should receive antiplatelet and anticoagulant therapy according to GDMT and should be strongly considered for early invasive strategy because of their increased risk.143,145,177,178,189,190 (Class I, Level of Evidence: B) 5. Women with NSTE-ACS and high-risk features (eg, troponin positive) should undergo an early invasive strategy.172,173,178,191 (Class I, Level of Evidence: A) ACC indicates American College of Cardiology; ACS, acute coronary syndromes; AHA, American Heart Association; CABG, coronary artery bypass graft; ED, emergency department; GDMT, guideline-directed medical therapy; GRACE, Global Registry of Acute Coronary Events; MI, myocardial infarction; NSTE-ACS, non ST-elevation acute coronary syndrome; NSTEMI, non ST-elevation myocardial infarction; and TIMI, Thrombolysis in Myocardial Infarction. Appendix A. Continued 36 Short Title: QM-3: Therapeutic Hypothermia for STEMI Patients QM-3: STEMI: Therapeutic Hypothermia for Comatose STEMI Patients With Out-of-Hospital Cardiac Arrest Measure Description: Percentage of patients, age 18 y, with STEMI who become comatose after resuscitated out-of-hospital cardiac arrest (secondary to VF or pulseless VT) and who receive therapeutic hypothermia. Numerator Patients with acute STEMI (or its equivalent*) defined by characteristic symptoms of myocardial ischemia with diagnostic ST elevation on ECG, who are comatose after resuscitated out-of-hospital cardiac arrest (VF or pulseless VT), who receive therapeutic hypothermia *Patients with STEMI equivalent on ECG may have: 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. Denominator All patients with STEMI who are comatose after resuscitated out-of-hospital cardiac arrest (VF or pulseless VT) Denominator Exclusions Patients age <18 y Patients who die shortly after arrival (<12 h) Patients who become comfort care measures only or hospice shortly after arrival (<12 h) Patients who are transferred to another hospital for inpatient care shortly after arrival (<12 h) Patients received in transfer from the inpatient setting from another facility Denominator Exceptions Documentation of a medical reason for not receiving therapeutic hypothermia for comatose STEMI patients with out-of-hospital cardiac arrest (eg, intracranial hemorrhage, severe/active bleeding, significant hypotension refractory to multiple vasopressors, severe sepsis, pregnancy, other evidence of medical futility) 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 Therapeutic hypothermia in comatose patients with acute MI after certain types of cardiac arrest (predominantly related to VF or pulseless VT) has been shown to improve outcomes (eg, increased survival to hospital discharge with good neurologic function, higher rate of a favorable neurologic outcome, and possibly reduced intermediate-term mortality).12,192 194 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), including patients who undergo primary PCI.192 194 (Class I, Level of Evidence: B) ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; LBBB, left bundle branch block; MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; VF, ventricular fibrillation; and VT, ventricular tachycardia. Appendix A. Continued 37 Short Title: QM-4: Aldosterone Antagonist at Discharge QM-4: AMI: Aldosterone Antagonist Prescribed at Discharge Measure description: Percentage of eligible patients, age 18 y, hospitalized with AMI, who are prescribed an aldosterone antagonist at hospital discharge. Numerator Eligible* patients with AMI who are prescribed an aldosterone antagonist at hospital discharge *Eligible AMI patients for an aldosterone antagonist are patients with no contraindications who are already receiving an ACE inhibitor and beta blocker, and who have an EF 40%, and either HF or diabetes mellitus (aldosterone antagonists are appropriately used when the ACE inhibitor and/or beta blocker cannot be used or tolerated). 