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). Denominator All post-AMI patients who: [a] are receiving an ACE inhibitor and a beta blocker; AND [b] have a LVEF 40%; AND [c] have either diabetes mellitus or HF 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 an aldosterone antagonist at hospital discharge (eg, allergy or intolerance to aldosterone antagonist, significant renal dysfunction [Cr >2.5 mg/dL in men; >2.0 mg/dL in women], hyperkalemia [K >5.0 mEq/L]) Patient currently enrolled in a clinical trial related to AMI (eg, trials involving renin-angiotensin-aldosterone system inhibitors) 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 The EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival) study demonstrated benefits from adding eplerenone, a selective aldosterone antagonist, to ACE inhibitors or ARBs (in 87% of patients) and beta blockers (75%), including a 15% and 17% reduction in overall and cardiovascular mortality, respectively. Therefore, in the absence of contraindications, post-MI patients with HF may benefit from adding an aldosterone antagonist to an ACE inhibitor or ARB, and a beta blocker. Monitoring of patients renal function, electrolytes (screening for hyperkalemia, in particular), and blood pressure should be undertaken.11,12,29 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. An aldosterone antagonist should be given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus.29 (Class I, Level of Evidence: B) 2014 AHA/ACC Guideline for the Management of Patients with Non ST-Elevation Acute Coronary Syndromes11 1. Aldosterone blockade is recommended in post MI patients without significant renal dysfunction (creatinine >2.5 mg/dL in men or >2.0 mg/dL in women) or hyperkalemia (K +>5.0 mEq/L) who are receiving therapeutic doses of ACE inhibitor and beta blocker and have a LVEF 0.40 or less, diabetes mellitus, (Class I, Level of Evidence: A) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Founcation; ACE, angiotensin-converting enzyme; AHA, American Heart Association; AMI, acute myocardial infarction; ARB, angiotensin receptor blockers; Cr, creatinine; EF, ejection fraction; K, potassium; HF, heart failure; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 38 Short Title: QM-5: Inappropriate In-Hospital Use of NSAIDs QM-5: AMI: Inappropriate In-Hospital Use of NSAIDs Measure Description: Percentage of patients, age 18 y, hospitalized with AMI who are inappropriately prescribed NSAIDs during hospitalization. Numerator Patients with AMI who were prescribed NSAIDs (with the exception of aspirin) in the hospital For purposes of this measure, a noninclusive list of NSAIDs include these medications: Ibuprofen Ketoprofen Sulindac Naproxen Etodolac Fenoprofen Diclofenac Flurbiprofen Ketorolac Piroxicam Indomethacin Mefenamic Acid Meloxicam Celecoxib Nabumetone Oxaprozin Ketoprofen Meclofenamate Tolmeti Salsalate Denominator All patients with AMI Denominator Exclusions Patients age <18 y Denominator Exceptions Documentation of a medical reason for prescribing NSAIDs during the AMI hospitalization (eg, patient with refractory arthritis pain that is unresponsive to other analgesics) 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 NSAIDs likely increase the risk of major adverse events in patients with myocardial infarction (eg, impaired infarct healing, possibly increased risk of rupture following transmural infarction, higher risk of accompanying acute kidney injury, and increased risk of gastrointestinal bleeding in at-risk AMI patients who are already receiving antithrombotic therapies).195,196 Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Glucocorticoids and nonsteroidal anti-inflammatory drugs are potentially harmful for treatment of pericarditis after STEMI.197,198 (Class III, Level of Evidence: B) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. Nonsteroidal anti-inflammatory drugs (NSAIDs) (except aspirin) should not be initiated and should be discontinued during hospitalization for NSTE-ACS because of the increased risk of MACE associated with their use.195,196 (Class III, Level of Evidence: B) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; AMI, acute myocardial infarction; MACE, major adverse cardiac events; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTE-ACS, non ST-elevation acute coronary syndrome; STEMI, ST-elevation myocardial infarction. Appendix A. Continued 39 Short Title: QM-6: Inappropriate Prasugrel at Discharge in TIA/Stroke Patients QM-6: AMI: Inappropriate Prescription of Prasugrel at Discharge in Patients With a History of Prior Stroke or TIA Measure Description: Percentage of patients, age 18 y, hospitalized with AMI, who had a history of prior stroke or TIA and who are inappropriately prescribed prasugrel at discharge. Numerator Patients with AMI who are prescribed prasugeral at discharge Denominator All patients with AMI and a history of prior stroke (ischemic or hemorrhagic) or TIA 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 The TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel Thrombolysis in Myocardial Infarction) randomized clinical trial demonstrated the superiority of prasugrel over clopidogrel in reducing the composite of cardiovascular death, nonfatal MI, or nonfatal stroke among AMI patients (albeit with an increased risk of major bleeding). Although the elderly and underweight patients did not experience net clinical benefit from the use of prasugrel, the subgroup of patients with TIA or stroke had an increased net clinical harm with prasugrel compared with clopidogrel.12,116 Notably, a history of ischemic or hemorrhagic stroke or TIA symptoms were considered exclusion criteria in the TRITON-TIMI 38 trial, although a small group ended up being randomized in error and exhibited increased harm with prasugrel. Subsequently, the FDA issued a boxed warning cautioning against the use of prasugrel in patients with TIA or stroke. Overall, patients with prior history of ischemic or hemorrhagic stroke or TIA symptoms should not receive prasugrel. Although ischemic stroke is defined as a permanent infarction (symptomatic or asymptomatic) of the central nervous system, TIA is defined as a transient neurologic dysfunction caused by focal ischemia without ensuing infarction. Hemorrhagic strokes result from either subarachnoid or intracerebral bleeding, and usually represent 20% of all stroke events. Clinical Recommendation(s) 2013 ACCF/AHA Guideline for the Management of Patients With ST-Elevation Myocardial Infarction12 1. Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack.116 (Class III, Level of Evidence: B) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack.116 (Class III, Level of Evidence: B) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; AMI acute myocardial infarction; and TIA, transient ischemic attack. Appendix A. Continued 40 Short Title: QM-7: Inappropriate High-Dose Aspirin With Ticagrelor at Discharge QM-7: AMI: Inappropriate Prescription of High-Dose Aspirin With Ticagrelor at Discharge Measure Description: Percentage of patients, age 18 y, hospitalized with AMI who are prescribed ticagrelor and high-dose aspirin at discharge. Numerator Patients with AMI who are prescribed ticagrelor and high-dose aspirin at discharge Note: The recommended maintenance dose of aspirin is 81 mg daily in patients treated with ticagrelor. A high-dose aspirin is defined as a daily maintenance dose >100 mg. In the United States, a high-dose aspirin for thromboprophylaxis is usually a 162 mg or a 325-mg regimen. Denominator All patients with AMI who are prescribed ticagrelor at discharge 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 In the PLATO (Platelet Inhibition and Patient Outcomes) trial, a prespecified subgroup analysis showed a significant regional variation in the comparative efficacy of ticagrelor with diminished benefits in North America compared with the rest of the world. Subsequent analyses demonstrated that the lowest risk of the composite ischemic outcome with ticagrelor compared with clopidogrel is associated with a low-maintenance dose of concomitant aspirin.7,12,40 Overall, a high- dose aspirin (>100 mg) is associated with increased bleeding hazard without an improved antiplatelet efficacy. The FDA also issued a boxed warning indicating that aspirin daily maintenance doses of >100 mg decrease the effectiveness of ticagrelor. 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. 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. Aspirin should be continued indefinitely. The maintenance dose should be 81 mg daily in patients treated with ticagrelor and 81 mg to 325 mg daily in all (Class I, Level of Evidence: A) ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; AMI, acute myocardial infarction; FDA, US Food and Drug Administration; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. Appendix A. Continued 41 Appendix B. Author Listing of Relationships With Industry and Other Entities (Relevant) 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non ST-Elevation Myocardial Infarction Committee Member Employment Consultant Speaker Ownership/ Partnership/ Principal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Hani Jneid, Chair Baylor College of Medicine Associate Professor of Medicine; Director of Interventional Cardiology Research The Michael DeBakey VA Medical Center Director of Interventional Cardiology None None None None None None Daniel Addison Fellow at Massachusetts General Hospital None None None None None None Deepak L. Bhatt Executive Director of Interventional Cardiovascular Programs, Brigham and Women s Hospital Heart & Vascular Center; Harvard Medical School Professor of Medicine Duke Clinical Research Institute: Ferring Pharmaceuticals Duke Clinical Research Institute: Novartis Duke Clinical Research Institute: Bristol-Myers Squibb/Pfizer Duke Clinical Research Institute: Eli Lilly None None Amarin Amgen Inc. AstraZeneca BIOFLOW-V (Biotronik)-clinical trial Bristol Myers Squibb Eisai Ethicon EVOLVE Short DAPT Study (Boston Scientific) Flowco* Forest Laboratories Ischemix Medtronic Merck and Co, Inc* Pfizer PLxPharma* Roche Sanofi Aventis Takeda* The Medicines Company Cardax* Duke Clinical Research Institute Data Safety Monitoring Board Harvard Clinical Research Institute: Boehringer Ingelheim Harvard Clinical Research Institute: St. Jude Data Safety Monitoring Board Harvard Clinical Research Institute (St. Jude) Data Safety Monitoring Board Merck & Co., Inc. Planning Committee for Clinical Study* Novartis None Gregg C. Fonarow Ahmanson-UCLA Cardiomyopathy Center Division of Cardiology Director of UCLA's Cardiology Fellowship Program Amgen Boston Scientific Janssen Johnson & Johnson Medtronic Novartis St. Jude Medical Takeda The Medicines Company ZS Pharma None None Medtronic Novartis None None Sana Gokak ACC/AHA None None None None None None (Continued) 42 Kathleen L. Grady Northwestern University Feinberg School of Medicine Professor of Surgery and Medicine; and Administrative Director for Heart Failure None None None None None None Lee A. Green University of Michigan Professor Emeritus None None None None None None Paul A. Heidenreich Stanford VA Palo Alto Health Care System Professor of Medicine None None None None None None P. Michael Ho VA Eastern Colorado Health Care System University of Colorado School of Medicine Associate Professor of Medicine Anthem, Inc. Janssen Pharmaceuticals, Inc Premier, Inc. Telligen* None None None None None Corrine Y. Jurgens Stony Brook University Associate Professor None None None None None None Marjorie L. King Helen Hayes Hospital None None None None None None Dharam J. Kumbhani UT Southwestern Medical Center Assistant Professor of Medicine None None None None None None Samir Pancholy The Wright Center for Graduate Medical Education None Medtronic Pfizer Terumo Medical Duke Clinical Research Institute Odyssey Outcomes Trial None None This table represents the relationships of committee members with industry and other entities that were reported by authors to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $5000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted.According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *No financial relationship. Significant (greater than $5000) relationship. ACC indicates American College of Cardiology; AHA, American Heart Association; BIOFLOW-V, A Prospective Randomized Multicenter Study to Assess the SaFety and Effectiveness of the Orsiro SiroLimus Eluting Coronary Stent System in the Treatment Of Subjects With up to Three De Novo or Restenotic Coronary Artery Lesions - V; EVOLVE DAPT, A Prospective, Multicenter, Single-arm Study Designed to Assess the Safety of 3-month Dual Antiplatelet Therapy in Subjects at High Risk for Bleeding Undergoing Percutaneous Coronary Intervention With the SYNERGY Everolimus-Eluting Platinum Chromium Coronary Stent System; and UT, University of Texas. Appendix B. Continued Committee Member Employment Consultant Speaker Ownership/ Partnership/ Principal Research Institutional, Organizational, or Other Financial Benefit Expert Witness 43 Appendix C. Peer Reviewer Relationships With Industry and Other Entities 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non ST-Elevation Myocardial Infarction Peer Reviewer Representation Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Randal Thomas Official TFPM Lead None None None None None None Timothy A. Dewhurst Official ACC BOG None None None Biotronik- Protoge Phase IV registry clinical trial enroller None None Fredrick A. Masoudi Official AHA None None None None None None Hitinder Gurm Official SCAI Osprey Medical None None None None None Michael Kontos Content: ACTION Steering Committee Astra Zeneca Medicure Roche Diagnostics None None None Astellas Novartis* None Matthew Roe Content: NCDR SQOC AstraZeneca Boehringer Ingelheim Pharmaceuticals, Inc Quest Diagnostics None None Daiichi-Sankyo Ely Lilly Janssen Pharmaceuticals Merck Sanofi-Aventis Bristol-Myers Squibb Company Eli Lilly and Company None Claire Duvernoy Content: AUCTF None None None None None None H. Vernon Anderson Content: ACC/ AHA TFDS None None None Capricor: ALLSTAR (Clinical Trial Enroller) DSMB: MedPace Medical Devices None Fredrick G. Kushner Content: ACC/ AHA TFPG None None None None None None Ezra Amsterdam Content: ACC/ AHA TFPG None None None None None None This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *No financial relationship. Significant (greater than $5000) relationship. ACC indicates American College of Cardiology; AHA, American Heart Association; ALLSTAR, The Allogeneic Heart Stem Cells to Achieve Myocardial Regeneration clinical trial; AUCTF, Appropriate Use Criteria Task Force; BOG, Board of Governors; DSMB, Data and Safety Monitoring Board; MER, Medical Education Resources; NCDR, National Cardiovascular Data Registry; NIH, National Institutes of Health; SCAI, Society for Cardiovascular Angiography and Interventions; SQOC, Science and Quality Oversight Committee; TFDS, Task Force on Data Standards; TFPG, Task Force on Practice Guidelines; TFPM, Task Force on Performance Measures; VA, US Department of Veterans Affairs; and VHAC, Virginia Heart Attack Coalition.