ACC/AHA TASK FORCE ON PERFORMANCE MEASURES Gregg C. Fonarow, MD, FACC, FAHA, Chair; Paul A. Heidenreich, MD, MS, FACC, FAHA, Immediate Past Chair; Nancy M. Albert, PhD, CCNS, CCRN, FAHA ; Geoffrey D. Barnes, MD, MSc, FACC ; Paul S. Chan, MD, MSc, FACC ; Lesley H. Curtis, PhD ; Lauren Gilstrap, MD ; Michelle Gurvitz, MD, FACC ; P. Michael Ho, MD, PhD, FACC, FAHA ; Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA ; Sean O Brien, PhD ; Jeffrey Olin, DO, FACC, FAHA ; Tiffany Randolph, MD ; Andrea M. Russo, MD, FACC ; Randal J. Thomas, MD, FACC, FAHA ; Paul D. Varosy, MD, FACC ; Robert Yeh, MD, FACC ; Samad Zaheeruddin, MD 2017 by the American Heart Association, Inc., and the American College of Cardiology Foundation. Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org DOI: 10.1161/HCQ.0000000000000032 *ACC/AHA Task Force on Performance Measures Liaison. Society for Cardiovascular Angiography and Interventions Representative. American College of Cardiology Representative. American Heart Association Representative. The American Heart Association and the American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This document was approved by the American College of Cardiology Clinical Policy Approval Committee on May 22, 2017, the American Heart Association Science Advisory and Coordinating Committee on June 7, 2017, the American Heart Association Executive Committee on August 11, 2017, and the Society for Cardiovascular Angiography and Interventions on July 17, 2017. The Comprehensive RWI Data Supplement table is available with this article at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/ HCQ.0000000000000032/-/DC1. The American Heart Association requests that this document be cited as follows: Jneid H, Addison D, Bhatt DL, Fonarow GC, Gokak S, Grady KL, Green LA, Heidenreich PA, Ho PM, Jurgens CY, King ML, Kumbhani DJ, Pancholy S. 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes. 2017;10:e000032. doi: 10.1161/HCQ.0000000000000032. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org). A copy of the document is available at http://professional.heart.org/statements by selecting either the By Topic link or the By Publication Date link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://professional.heart.org/statements and select the Policies and Development link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the Copyright Permissions Request Form appears on the right side of the page. (Circ Cardiovasc Qual Outcomes. 2017;10:e000032. DOI: 10.1161/HCQ.0000000000000032.) 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non ST-Elevation Myocardial Infarction A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures Developed in Collaboration With the Society for Cardiovascular Angiography and Interventions Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation WRITING COMMITTEE MEMBERS Hani Jneid, MD, FACC, FAHA, Chair; Daniel Addison, MD; Deepak L. Bhatt, MD, MPH, FACC, FAHA; Gregg C. Fonarow, MD, FACC, FAHA; Sana Gokak, MPH; Kathleen L. Grady, PhD, FAHA; Lee A. Green, MD, MPH; Paul A. Heidenreich, MD, MS, FACC, FAHA*; P. Michael Ho, MD, PhD, FACC, FAHA; Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA; Marjorie L. King, MD, FACC; Dharam J. Kumbhani, MD, SM, FACC, FAHA; Samir Pancholy, MD, FACC AHA/ACC Performance Measures 2 Table of Contents Scope of the Problem 3 Disclosure of Relationships With Industry and Other Entities 4 Definition and Selection of Measures 5 AHA/ACC STEMI and NSTEMI Measure Set Performance Measures 6 Discussion of Changes to 2008 STEMI and NSTEMI Measure Set 6 Areas for Further Research 9 Appendix A STEMI and NSTEMI Performance Measures 15 Performance Measures for Use in Patients With Inpatient STEMI and NSTEMI 15 Inpatient Measures 15 Short Title: PM-1: Aspirin at Arrival 15 Short Title: Short Title: PM-3: Beta Blocker at Short Title: PM-4: High-Intensity Statin Short Title: Short Title: Short Title: Short Title: PM-8: First Medical Short Title: Short Title: PM-10: Door-in-Door-Out Time 22 Short Title: PM-11: Time to Primary PCI Among Transferred Patients 24 Short Title: PM-12: Cardiac Rehabilitation Short Title: Inhibitor at Short Title: PM-14: ImmediateAngiography After Cardiac Arrest 26 Short Title: PM-15: Stress Test in Conservatively Treated Patients 27 Short Title: PM-16: Early Troponin Measurement After NSTEMI 28 Short Title: PM-17: AMI Registry Quality Improvement Measures for Inpatient STEMI and NSTEMI Patients 29 Inpatient Measures 29 Short Title: QM-1: Risk Score Stratification Short Title: QM-2: Early Invasive Strategy for High-Risk NSTEMI 30 Short Title: Hypothermia for STEMI Patients 31 Short Title: QM-4: Aldosterone Antagonist Short Title: QM-5: Inappropriate In-Hospital Use of NSAIDs 32 Short Title: Prasugrel at Discharge in Short Title: High-Dose Aspirin With Ticagrelor at Discharge 34 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 35 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 37 Preamble The American College of Cardiology (ACC)/American Heart Association (AHA) performance measure sets serve as vehi- cles to accelerate translation of scientific evidence into clini- cal practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement. Writing committees are instructed to consider the meth- odology of performance measure development1 and to ensure that the measures developed are aligned with ACC/AHA clinical practice guidelines. The writing committees also are charged with constructing measures that maximally cap- ture important aspects of care quality, including timeliness, safety, effectiveness, efficiency, equity, and patient-centered- ness, while minimizing, when possible, the reporting burden imposed on hospitals, practices, and/or practitioners. Potential challenges from measure implementation may lead to unintended consequences. The manner in which chal- lenges are addressed is dependent on several factors, includ- ing the measure design, data collection method, performance attribution, baseline performance rates, reporting methods, and incentives linked to these reports. The ACC/AHA Task Force on Performance Measures (Task Force) distinguishes quality measures from performance measures. Quality measures are those metrics that may be use- ful for local quality improvement but are not yet appropriate for public reporting or pay for performance programs (uses of performance measures). New measures are initially evalu- ated for potential inclusion as performance measures. In some cases, a measure is insufficiently supported by the guidelines. In other instances, when the guidelines support a measure, the writing committee may feel it is necessary to have the measure tested to identify the consequences of measure implementation. Quality measures may then be promoted to the status of per- formance measures as supporting evidence becomes available. Gregg C. Fonarow, MD, FACC, FAHA Chair, ACC/AHA Task Force on Performance Measures 3 In the summer of 2015, the Task Force convened the writing committee to begin the process of revising the existing set of performance measures for adult patients hospitalized with ST-Elevation and Non ST-Elevation Myocardial Infarction (STEMI and NSTEMI, respectively), that was last updated in The writing committee was charged with the task of developing new measures to benchmark and improve the qual- ity of care for patients with STEMI and NSTEMI. All the measures included in the measure set are briefly summarized in Table 1, which provides information on the measure number, title, care setting, attribution, and domain. The detailed measure specifications (available in Appendix A) provide not only the information included in Table 1, but also more detailed information including the measure description, numerator, denominator (including denominator exclusions and exceptions), rationale for the measure, guideline recom- mendations that support the measure, measurement period, and sources of data. The writing committee has developed a comprehensive STEMI/NSTEMI measure set that includes 24 total measures of which 17 are performance measures and 7 are quality mea- sures (as reflected in Table 1 and Appendix A). The writing committee believes that implementation of this measure set by healthcare providers, physician practices, and hospital sys- tems will enhance the quality of care and likely improve out- comes of patients with STEMI and NSTEMI. 1.1. Scope of the Problem Acute myocardial infarction (AMI) is a frequent cause of hospital admission in the United States and is associated with significant short- and long-term mortality and mor- bidity. Every 42 seconds, approximately 1 American will suffer an AMI, and the estimated annual incidences of new and recurrent MI events are 550 000 and 200 000 events, Fortunately, the rates of hospitalization and 30-day mor- tality for AMI have been on the decline.4,5 This reduction in mortality is likely related to the shift in the pattern of clinical presentation of AMI as well as to improved acute treatments and long-term care. Yeh and colleagues examined age- and sex-adjusted incidence rates for STEMI and NSTEMI from a community-based population (Northern California) between 1999 and 2008, and demonstrated an overall significant decrease in AMI incidence rate after 2000.6 Although the adjusted 30-day mortality rate after AMI decreased signifi- cantly (driven by a significant reduction in NSTEMI mortal- ity), the overall mortality rate in 2008 after an AMI was still Importantly, AMI patients who survive the initial event have substantial risk for future cardiovascular events, includ- ing recurrent MI, death, heart failure, and stroke. In the PLATO (Platelet Inhibition and Patient Outcomes) trial, the rate of the combined cardiovascular endpoint (vascular death, MI, or stroke) was 11.7% at 12 months among AMI patients treated with aspirin and clopidogrel.7 This included a 6.9% rate of recurrent MI at 12 months.7 In 2010 alone, about 595000 inpatient hospital discharges were attributed to AMI.3 AMI is also associated with a substantial direct and indirect cost burden, and is classified among the top 10 most expensive hospital principal discharge diagnoses.3 As indicated in the Third Universal Definition of Myocardial Infarction consensus document published in AMI is defined by the detection of a rise and/or fall of cardiac biomarkers (preferably cardiac troponin levels) with at least 1 value above the 99th percentile upper reference limit and with at least one of the following: (a) symptoms of ischemia; (b) new or presumed new signi cant ST-segment T wave changes or new left bundle branch block; (c) develop- ment of pathological Q waves in the electrocardiogram (ECG); (d) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality; (e) identi cation of an intracoronary thrombus by angiography or autopsy. The Third Universal Definition of Myocardial Infarction consen- sus document, published in 2012, classifies MI into 5 types, based on pathological, clinical, and prognostic differences, along with different treatment strategies.8 The performance and quality measures described in the current document are predominantly pertinent to patients with spontaneous MI, or MI type 1. MI type 1 is an event related to atherosclerotic plaque disruption (eg, rupture, ulceration, erosion) with super- imposed thrombus formation in a coronary artery, resulting in acute reduction in myocardial blood supply and/or distal embolization with subsequent myonecrosis. MI type 2 is myocardial injury caused by conditions other than coronary artery disease that results in an imbalance between myocardial oxygen supply and/or demand (eg, coronary artery embolism or spasm, tachyarrhythmias, anemia, respiratory failure, pro- found hypotension). The measure set developed by our writing committee applies only to MI type 1 and does not uniformly apply to the other 4 types of MI. In fact, some of those measures are even contraindicated with certain MI type, such as aspirin or receptor inhibitor therapies, which are contraindicated in patients with a MI type 2 resulting from severe hemorrhage and anemia. Given the widespread use of very sensitive assays for markers of myocardial necrosis (eg, the highly sensitive and specific cardiac troponin [cTn] biomarkers) and advanced imaging modalities, very small amounts of myonecrosis unre- lated to ischemia can be detected (eg, heart failure, renal fail- ure, myocarditis, pulmonary embolism). Our measures also do not apply to these myocardial injury events, which should be differentiated from true AMI events. For the sake of immediate treatment strategies (eg, reperfu- sion therapy),AMI is differentiated into STEMI and NSTEMI, depending on the existence of ST-segment elevation in 2 contiguous leads on the presenting ECG. Acute STEMI equiv- alent can, however, manifest as: hyperacute T-wave changes, true posterior MI, multilead ST depression with coexistent ST elevation in lead aVR, characteristic diagnostic criteria in the setting of left bundle branch block. The proportion of STEMI versus NSTEMI events varies in different registries and depends on the age of patients, their geographic location, and the type of surveillance used. In general, STEMI patients account for 29% to 47% of all AMI patients.9,10 Updating the existing STEMI/NSTEMI measure set was a priority for the ACC and AHA. Particular attention was given to evidence-based diagnostic and therapeutic strategies that 4 have high impact on outcomes (eg, Class I or III guideline recommendations) of patients with STEMI/NSTEMI and that satisfy the attributes of performance measures (eg, feasible, reliable, actionable). This writing committee developed the measures in this document after comprehensive examination of the most current relevant guidelines, internal discussion and internal voting, peer review, and public comment. 1.2. Disclosure of Relationships With Industry and Other Entities The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that could arise as a result of relationships with industry or other entities (RWI). Detailed information on the ACC/AHA policy on RWI can be found online. All members of the writing committee, as well as those Table 1. 2017 AHA/ACC STEMI and NSTEMI Myocardial Infarction Clinical Performance and Quality Measures No. Measure Title Care Setting Attribution Measure Domain Performance Measures PM-1 Aspirin at Arrival Inpatient Facility or Provider Level Effective Clinical Care PM-2 Aspirin Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-3 Beta Blocker Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-4 High-Intensity Statin Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-5 Evaluation of LVEF Inpatient Facility or Provider Level Effective Clinical Care PM-6 ACEI or ARB Prescribed for LVSD Inpatient Facility or Provider Level Effective Clinical Care PM-7 Time to Fibrinolytic Therapy* Inpatient Facility or Provider Level Communication and Care Coordination PM-8 Time to Primary PCI* Inpatient Facility or Provider Level Communication and Care Coordination PM-9 Reperfusion Therapy* Inpatient Facility or Provider Level Effective Clinical Care PM-10 Time From ED Arrival at STEMI Referral Facility to ED Discharge From STEMI Referral Facility in Patients Transferred for Primary PCI* Inpatient Facility Level Communication and Care Coordination PM-11 Time From FMC (At or Before ED Arrival at STEMI Referral Facility) to Primary PCI at STEMI Receiving Facility Among Transferred Patients* Inpatient Facility Level Communication and Care Coordination PM-12 Cardiac Rehabilitation Patient Referral From an Inpatient Setting Inpatient Facility or Provider Level Communication and Care Coordination PM-13 PY12 Receptor Inhibitor Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care PM-14 Immediate Angiography for Resuscitated Out-of-Hospital Cardiac Arrest in STEMI Patients* Inpatient Facility or Provider Level Effective Clinical Care PM-15 Noninvasive Stress Testing Before Discharge in Conservatively Treated Patients Inpatient Facility or Provider Level Efficiency and Cost Reduction PM-16 Early Cardiac Troponin Measurement (Within 6 Hours of Arrival) Inpatient Facility or Provider Level Efficiency and Cost Reduction PM-17 Participation in 1 Regional or National Registries That Include Patients With Acute Myocardial Infarction Registry Inpatient Facility Level Community, Population, and Public Health Quality Measures QM-1 Risk Stratification of NSTEMI Patients With a Risk Score Inpatient Facility or Provider Level Effective Clinical Care QM-2 Early Invasive Strategy (Within 24 Hours) in High-Risk NSTEMI Patients Inpatient Facility or Provider Level Effective Clinical Care QM-3 Therapeutic Hypothermia for Comatose STEMI Patients With Out- of-Hospital Cardiac Arrest* Inpatient Facility or Provider Level Effective Clinical Care QM-4 Aldosterone Antagonist Prescribed at Discharge Inpatient Facility or Provider Level Effective Clinical Care QM-5 Inappropriate In-Hospital Use of NSAIDs Inpatient Facility or Provider Level Patient Safety QM-6 Inappropriate Prescription of Prasugrel at Discharge in Patients With a History of Prior Stroke or TIA Inpatient Facility or Provider Level Patient Safety QM-7 Inappropriate Prescription of High-Dose Aspirin With Ticagrelor at Discharge Inpatient Facility or Provider Level Patient Safety *These measures apply only to patients with STEMI. These measures apply only to patients with NSTEMI. ACC indicates American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; ED, emergency department; FMC, first medical contact; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; NSAIDs, nonsteroidal anti- inflammatory drugs; NSTEMI, non ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; PM, performance measures; QM, quality measures; STEMI, ST-elevation myocardial infarction; and TIA, transient ischemic attack. 5 selected to serve as peer reviewers of this document, were required to disclose all current relationships and those exist- ing within the 12 months before the initiation of this writing effort. ACC/AHA policy also requires that the writing com- mittee chairs and at least 50% of the writing committee have no relevant RWI. Any writing committee member who develops new RWI during his or her tenure on the writing committee is required to notify staff in writing. These statements are reviewed peri- odically by the Task Force and by members of the writing committee. Author and peer reviewer RWI which are rele- vant to the document are included in the appendixes: Please see Appendix B for relevant writing committee RWI and Appendix C for relevant peer reviewer RWI. Additionally, to ensure complete transparency, the writing committee mem- bers comprehensive disclosure information, including RWI not relevant to the present document, is available online. Disclosure information for the Task Force is also available online. The work of the writing committee was supported exclu- sively by the ACC and the AHA without commercial support. Members of the writing committee volunteered their time for this effort. Meetings of the writing committee were confiden- tial and attended only by writing committee members and staff from the ACC, AHA, and the Society for Cardiovascular Angiography and Interventions who served as a collaborator on this project. 2.1. Literature Review In developing the updated STEMI/NSTEMI measure set, the writing committee reviewed evidence-based guidelines and statements that would potentially impact the construct of the measures. The practice guidelines and statements that most directly contributed to the development of these measures are summarized in Table 2. 2.2. Definition and Selection of Measures The writing committee reviewed recent clinical practice guidelines and other clinical guidance documents (Table 2). The writing committee also examined available information on disparities in care to address which new measures might be appropriate as performance versus quality measures for this measure set update. To this effect, an extensive environ- mental scan of the published literature was performed. In a large retrospective analysis of STEMI patients transferred to primary percutaneous coronary intervention (PCI) centers in the ACTION-Get With The Guidelines registry (2007-2010), only 11% had timely door-in-door-out time 30 minutes.20 In another cohort of STEMI patients transferred from non PCI- capable hospitals to STEMI receiving centers (2008-2012), timely primary PCI ( 120 minutes) was achieved in 65% of Another report showed that only 41% of patients were referred to cardiac rehabilitation after AMI.22,23 These reports highlight but a few examples of the persistent disparities in care. Importantly, it appears guideline-directed care can greatly reduce a large proportion of disparities previ- ously noted in women.24,25 All measures were designed to assess quality of care experienced by individuals who have STEMI or NSTEMI in the inpatient setting. Each measure was designed to limit performance measurement to patients without a valid rea- son for exclusion from the measure. Measure exclusions were those reasons that remove a patient from the denomi- nator, regardless of whether they would be included in the numerator. For example, all measures excluded patients who were <18 years of age, who received comfort care measures only, or in hospice. In contrast to exclusions, denominator exceptions were those conditions that removed a patient from the denominator only if the numerator criteria were not met. Denominator exceptions were used in select cases to allow for a fairer measurement of quality for those providers with higher risk populations. Exceptions were also used to defer to the clinical judgment of the provider. Several of the measures included exceptions. For example, in the case of Inhibitor at Discharge measure, a care provider may write a prescription for an oral P2Y12 receptor inhibi- tor (clopidogrel, ticagrelor, or prasugrel) even if the patient revealed that he/she will not take the medication due to a Table 2. Associated Guidelines and Other Clinical Guidance Documents Clinical Practice Guidelines 1. 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 2. 2013 ACCF/AHA Guideline for the Management of ST-Elevation 3. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular 4. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults14 5. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/ AHA Guideline for the Management of ST-Elevation Myocardial 6. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease16 7. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure17 Statements/Performance Measures 1. 2015 ACC/AHA Focused Update of Secondary Prevention Lipid 2. Third Universal Definition of Myocardial Infarction8 3. ACC/AHA 2008 Performance Measures for Adults With ST- Elevation and Non ST-Elevation Myocardial Infarction2 4. ACC/AHA 2008 Statement on Performance Measurement and ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; ESC indicates European Society of Cardiology; HFSA, Heart Failure Society of America; and SCAI, Society for Cardiovascular Angiography and Interventions. 6 number of reasons (eg, concerns about its bleeding risk). In this case, the provider would receive credit for the measure. However, if the patient had explicitly expressed to the pro- vider that he/she did not wish to have the medication pre- scribed, no prescription will be written and the provider can then document in the medical record patient s refusal of the medication. In this scenario, the provider will not be penal- ized for this performance measure because a valid patient reason is documented. The writing committee closely delib- erated the exceptions to be included with each measure and, in some cases, determined not to include any exceptions (as in the case of the patient safety measures). During the course of developing the measure set, the writing committee evaluated the potential measures against the ACC/AHA attributes of performance measures (Table 3) to reach consensus on which measures should be advanced for inclusion in the final measure set. After the peer review and public comment period, the writing committee reviewed and discussed the comments received, and further refined the measure set. The writing committee acknowledges that the new measures created in this set will need to be tested and validated over time. By publishing this performance and quality measure set, the writing committee hopes to encourage their widespread and expeditious adoption, as well as facilitate the collection and analysis of data that are needed to continuously assess their relevance over time. In the future, the writing committee members anticipate having data that will allow them to reassess whether any of the mea- sures included in this set should be revised (eg, modified, deleted, or potentially upgraded from a quality measure to a performance measure). 3. AHA/ACC STEMI and NSTEMI Measure Set Performance Measures 3.1. Discussion of Changes to 2008 STEMI and NSTEMI Measure Set After reviewing the existing guidelines, and the 2008 per- formance and quality measure set,2 the writing committee discussed which measures should be revised to reflect the updated science, and worked to identify which guideline rec- ommendations could serve as the basis for new performance or quality measures. The writing committee also reviewed existing measure sets that were publicly available. The following subsections serve as a synopsis of the revi- sions that were made to previous measures, and a description of why the new inpatient measures were created. 3.1.1. Retired Measures The writing committee decided to retire 1 performance mea- sure for smoking cessation counseling because of the consis- tently high levels of performance achieved (Table 4). Other quality measures, previously included as test measures in the 2008 measure set, were retired for the reasons specified in Table 4. 3.1.2. Revised Measures The writing committee reviewed and made changes to 4 mea- sures, which are summarized inTable 5. Most the changes were Table 3. ACC/AHA Task Force on Performance Measures: Attributes for Performance Measures26 1. Evidence Based High-impact area that is useful in improving patient outcomes a) For structural measures, the structure should be closely linked to a meaningful process of care that in turn is linked to a meaningful patient outcome. b) For process measures, the scientific basis for the measure should be well established, and the process should be closely linked to a meaningful patient outcome. c) For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measures based on outcomes should adjust for relevant clinical characteristics through the use of appropriate methodology and high- quality data sources. 2. Measure Selection Measure definition a) The patient group to whom the measure applies (denominator) and the patient group for whom conformance is achieved (numerator) are clearly defined and clinically meaningful. Measure exceptions and exclusions b) Exceptions and exclusions are supported by evidence. Reliability c) The measure is reproducible across organizations and delivery settings. Face validity d) The measure appears to assess what it is intended to. Content validity e) The measure captures most meaningful aspects of care. Construct validity f) The measure correlates well with other measures of the same aspect of care. 3. Measure Feasibility Reasonable effort and cost a) The data required for the measure can be obtained with reasonable effort and cost. Reasonable time period b) The data required for the measure can be obtained within the period allowed for data collection. Actionable a) Those held accountable can affect the care process or outcome. Unintended consequences avoided b) The likelihood of negative unintended consequences with the measure is low. ACC indicates American College of Cardiology; AHA, American Heart Association. 7 Table 4. Retired STEMI and NSTEMI Measures From the 2008 Set # Care Setting Measure Title Rationale for Retiring the Measure PM-12 Inpatient Adult Smoking Cessation Advice/ Counseling This measure is being retired because perfect scores are consistently achieved and the measure appears to have reached a ceiling effect. Therefore, given absence of room for further improvement, the writing committee opted to omit this measure from the inpatient performance measure set for AMI (realizing also that a separate outpatient CAD measure set will likely address smoking cessation advice/counseling). The writing committee also recognizes the importance of the American Medical Association/Physician Consortium for Performance Improvement Tobacco Use: Screening and Cessation Intervention measure that already exists.27 QM-1 Inpatient LDL Cholesterol Assessment This measure is being retired to be concordant with the new lipid guidelines that no longer recommend LDL measurements to target statin prescription and/or dosing. QM-2 Inpatient Excessive Initial Heparin Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as under-dosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-3 Inpatient Excessive Initial Enoxaparin Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-4 Inpatient Excessive Initial Abciximab Dose This measure is being retired because it covers only one aspect of medication use, (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-5 Inpatient Excessive Initial Eptifibatide Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-6 Inpatient Excessive Initial Tirofiban Dose This measure is being retired because it covers only one aspect of medication use (eg, overdosing) and misses other aspects such as underdosing and inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-7 Inpatient Anticoagulant Dosing Protocol This measure is being retired because it covers only one aspect of medication use and misses other aspects such as inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines and has shortcomings pertinent to measure feasibility and accountability. QM-8 Inpatient Anticoagulant Error Tracking System This measure is being retired because it covers only limited aspects of medication use and misses other aspects such as inappropriate use. In addition, this is not a direct stand-alone Class I or III recommendation in the guidelines. AMI indicates acute myocardial infarction; LDL, low-density lipoprotein; NSTEMI, non ST-elevation myocardial infarction; PM, performance measure; QM, quality measure; and STEMI, ST-elevation myocardial infarction. Table 5. Revised STEMI and NSTEMI Measures # Care Setting Measure Title Rationale for Revision of the Measure PM-4 Inpatient Statin for AMI This measure is being revised to reflect the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults,14 which recommended statin use for all patients with established atherosclerotic cardiovascular disease, including patients with AMI. PM- 5 Inpatient Evaluation of LVEF The title of this measure is being revised from Evaluation of Left Ventricular Systolic Function to Evaluation of Left Ventricular Ejection Fraction. The treatment recommendations regarding the use of guideline-directed medication therapies are based on LVEF, not qualitative estimates of left ventricular systolic function. The 2013 ACCF/AHA STEMI explicitly recommended measuring LVEF. The 2014 AHA/ACC NSTE-ACS guidelines11 likewise have medication recommendations based on knowledge of the ejection fraction. PM-12 Inpatient Cardiac Rehabilitation Referral This measure is being adapted from the AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services.28 One modification since the publication of that 2010 measurement set was the removal of patient reasons from the list of measure exceptions. Specifically, patient refusal does not constitute a justifiable reason for a clinician not offering a referral to a patient. If documentation in the medical record exists noting that the provider has informed and discussed referral to cardiac rehabilitation/secondary prevention program with the patient, but that the patient refuses a referral, then the healthcare provider would not be expected to send communication about the patient to the cardiac rehabilitation/secondary prevention program. This is consistent with HIPAA confidentiality regulations and shared decision making, and performance would then be considered met by the provider (preventing unjust penalization of the provider). Receptor Inhibitor Prescribed at Discharge In the 2008 ACC/AHA STEMI/NSTEMI measure set,2 a test measure entitled Clopidogrel at Discharge was included. Since then, 2 newer FDA-approved medications ticagrelor and prasugrel have emerged and demonstrated safety, efficacy, and clinical effectiveness after AMI. All 3 medications are inhibitors of the P2Y12 receptor and are recommended in addition to aspirin (as part of a dual antiplatelet regimen) to reduce recurrent ischemic events after AMI. AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; AMI, acute myocardial infarction; FDA, US Food and Drug Administration; HIPAA, the Health Insurance Portability and Accountability Act; LVEF, left ventricular ejection fraction; NSTEMI, non ST-elevation myocardial infarction; NSTE-ACS, non ST-segment elevation acute coronary syndromes; PM, performance measure; and STEMI, ST-elevation myocardial infarction. 8 Table 6. New STEMI/NSTEMI Measures No. Care Setting Measure Title Rationale for Creating New Measure Rationale for Designating as a Quality Measure as Opposed to a Performance Measure (If Applicable) PM-14 Inpatient Immediate Angiography for Resuscitated Out- of-Hospital Cardiac Arrest in STEMI Patients This measure seeks to implement a Class I (Level of Evidence B) recommendation in the 2013 ACCF/AHA STEMI guideline12 that immediate angiography with PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI. The writing committee opted to include angiography only, which is easily measurable, and not PCI because of the difficulty associated with ascertaining PCI appropriateness or its lack thereof. Not Applicable PM-15 Inpatient Noninvasive Stress Testing Before Discharge in Conservatively Treated Patients This measure seeks to implement Class I (Level of Evidence B) recommendations in both the guidelines to perform noninvasive stress testing to detect inducible ischemia in medically treated STEMI and NSTEMI patients. Not Applicable PM-16 Inpatient Early Cardiac Troponin Measurement (Within 6 Hours of Arrival) This measure seeks to implement Class I (Level of Evidence A) recommendations in the 2014 AHA/ACC NSTE-ACS guideline11 to measure serial cardiac troponin levels (at presentation and 3 to 6 h after symptom onset in all patients). Not Applicable PM-17 Inpatient Participation in Regional or National Acute Myocardial Infarction Registry This measure seeks to implement Class I (Level of Evidence B) and Class IIa (Level of Evidence B) recommendations in the 2013 STEMI12 AHA/ACC NSTE-ACS guidelines,11 respectively. The writing group felt that participation in a regional or national AMI registry will help track and assess the outcomes, complications, and quality of care for patients with AMI, and is supported by evidence. Not Applicable QM-1 Inpatient Risk Score Stratification for NSTEMI Patients This measure seeks to implement a Class I (Level of Evidence A) recommendation in the 2014 guideline that risk scores should be used to assess prognosis in patients with NSTE-ACS. The writing committee realizes the importance of this measure to dictate the appropriate strategy (invasive versus ischemic- guided) and the timing of the strategy (early versus late invasive) in patients with NSTEMI. The writing committee felt it was best to keep this as a quality measure because of issues related to the measure feasibility. Most registries do not include risk scores, and most risk scores (eg, GRACE, TIMI, PURSUIT) are difficult to compute retrospectively from their respective components, and are likely to cause a significant abstraction burden. QM-2 Inpatient Early Invasive Strategy (Within 24 Hours) in High-Risk NSTEMI Patients This measure seeks to implement a Class I (Level of Evidence A) recommendation in the 2014 AHA/ ACC NSTE-ACS guideline11 that an early invasive strategy should be performed in initially stabilized high-risk patients with NSTE-ACS. The writing committee felt it was best to keep this as a quality measure for many reasons. The writing group acknowledges that early invasive strategy (compared with a delayed invasive strategy) in high-risk NSTE-ACS patients predominantly reduces recurrent ischemia (rather than the hard outcomes of recurrent MI or death). Although this strategy additionally reduces length of stay and costs, it creates a logistical burden on cardiac catheterization labs, especially during weekends. Finally, objective risk stratification by risk scores is usually not available in current registries; thus, ascertaining which patients benefit from early invasive strategy may not be readily feasible. QM-3 Inpatient Therapeutic Hypothermia for Comatose STEMI Patients With Out- of-Hospital Cardiac Arrest This measure seeks to implement a Class I (Level of Evidence B) recommendation in the 2013 ACCF/AHA STEMI guideline12 that therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of- hospital cardiac arrest caused by VF or VT. The writing committee felt it was best to keep this as a quality measure because of newer controversial data pertinent to the effectiveness, timing, and implementation of therapeutic hypothermia. (Continued) 9 made to reflect the new evidence and updated guideline recom- mendations, to strengthen the measure construct, or to expand the measures to include new proven pharmacotherapies. 3.1.3. New Measures The new measure set includes 4 performance measures and 7 quality measures. Table 6 includes a list of the new measures and their rationale. Four of the quality measures are structured in a typical format in which the goal is to seek a score of 100%. However, 3 of the new quality measures (QM-5, QM-6, and QM-7) are safety measures and, in those, the goal is to seek a score of 0% (eg, 0% use or prescription of an inappropriate treatment reflects an optimal quality of care). For more detailed information on the measure construct, please refer to the detailed measure specifications summarized in Appendix A. 4. Areas for Further Research The writing committee recognizes that the ultimate measure of performance lies in the assessment of outcomes, such as mortality (in-hospital or 30-day), health status, and other outcomes (recurrent MI, urgent repeat revascularization). However, the complexity associated with adjustment for the large number of patient characteristics that both influence treatment decisions and impact mortality make these mea- sures less attractive to use. Thirty-day risk-adjusted AMI mortality has been used by CMS for payment incentives and in public reporting. The impact of these and other measures on hospital quality should be the focus of future research. The committee also realizes that many measures are already topped-out and can be retired to minimize abstraction burden. Additional research should examine the impact of dropping such measures. Furthermore, continuous research to examine temporal trends and disparities (ie, with respect to sex, age, ethnicity) in the achievement of performance and quality measures will help guide future revisions as well as the implementation of the current set. While the majority of current measures are binary (for example, yes or no for medication prescription), the next frontier in performance evaluation may be also to measure doses of prescribed pharmacotherapies and compare them to doses used in ran- domized trials showing benefit. Finally, the ACC ACTION Registry Get With The Guidelines implemented a Defect- Free Care measure for AMI patients, which was endorsed by the National Quality Forum. Our writing committee did not adopt this measure in the current document to avoid the additional burden of data abstraction and reporting. This is QM-4 Inpatient Aldosterone Antagonist at Discharge This measure seeks to implement Class I recommendations in the 2013 ACCF/AHA STEMI12 guidelines supporting the use of aldosterone antagonists in eligible patients with STEMI and NSTEMI, respectively. The writing committee felt it is best to keep this as a quality measure because of issues related to the measure construct. This measure is likely to present a significant abstraction burden and may be relevant only to a small fraction of AMI patients (given the elaborate inclusion/ exclusion criteria in the EPHESUS29 clinical trial). QM-5 Inpatient Inappropriate In- Hospital Use of NSAIDs This measure seeks to implement Class III recommendations (Class III Harm, Level of Evidence: B) in both the 2013 ACCF/AHA guidelines, cautioning against the use of these drugs after AMI. The writing committee felt it is best to keep this as a quality measure given the low impact associated with the use of NSAIDs during the brief hospitalization period (this is likely more relevant in the outpatient setting). The existence of an extensive and evolving list of NSAIDs may also create significant abstraction burden. QM-6 Inpatient Inappropriate Prescription of Prasugrel at Discharge in Patients With a History of Prior Stroke or TIA This measure seeks to implement Class III recommendations (Class III HARM, Level of Evidence: B) in both the 2013 ACCF/AHA STEMI12 guidelines, cautioning against the use of prasugrel in patients with prior TIA/stroke, because of net clinical harm in these patients. The FDA also issued a black box warning on this. The writing committee felt it is best to keep this as a quality measure only for the time being until more data become available pertinent to this measure and its impact in real-world patients. QM-7 Inpatient Inappropriate Prescription of High-Dose Aspirin With Ticagrelor at Discharge This measure seeks to implement Class III recommendations (Class III HARM, Level of Evidence: B) in both the 2013 ACCF/AHA STEMI12 guidelines, cautioning against the use of high-dose aspirin >100 mg among patients receiving ticagrelor. The FDA also issued a black box warning on this. The writing committee felt it is best to keep this as a quality measure only for the time being until more data become available pertinent to this measure and its impact in real-world patients. ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EPHESUS, Eplerenone Post Acute Myocardial Infarction Heart Failure Efficacy and Survival Study; FDA, US Food and Drug Administration; GRACE, Global Registry of Acute Coronary Events; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTE- ACS, non ST-segment elevation-acute coronary syndrome; NSTEMI, non ST-elevation myocardial infarction; PM, performance measure; PCI, percutaneous coronary intervention; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin; QM, quality measure; STEMI, ST-segment elevation myocardial infarction; TIA, transient ischemic attack; TIMI, Thrombolysis in Myocardial Infarction; VF, ventricular fibrillation; and VT, ventricular tachycardia. Table 6. Continued No. Care Setting Measure Title Rationale for Creating New Measure Rationale for Designating as a Quality Measure as Opposed to a Performance Measure (If Applicable) 10 especially important given that we have expanded the perfor- mance measure set to include a larger and more comprehen- sive set of 17 performance measures than previously adopted. Our writing committee acknowledges the importance of the Defect-Free Care measure and would like to evaluate its performance and impact in real world before considering it in the future. We also emphasize the importance of assess- ing the impact of compliance (or lack thereof) to some or all performance measures on short- and long-term clinical out- comes. Our writing committee also recognizes that all per- formance measures and quality measures are dynamic and can be revised or retired based on the emergence of scientific evidence and new guideline recommendations. Staff American College of Cardiology Mary Norine Walsh, MD, FACC, President Shalom Jacobovitz, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing Lara Slattery, MHS, Senior Director,ACC Scientific Reporting Esteban Perla, MPH, Team Lead, Quality Measurement Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/American Heart Association Katherine Sheehan, PhD, Director, Guideline Strategy and Operations Sana Gokak, MPH, Associate, Quality Measurement American Heart Association Steven R. Houser, PhD, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Jody Hundley, Production Manager, Scientific Publishing, Office of Science Operations References 1. Spertus JA, Eagle KA, Krumholz HM, et al. American College of Cardiology and American Heart Association methodology for the selec- tion and creation of performance measures for quantifying the quality of cardiovascular care. Circulation. 2005;111:1703 12. 2. Krumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008 per- formance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non-ST-Elevation Myocardial Infarction). Developed in collaboration with the American Academy of Family Physicians and American College of Emergency Physicians. Circulation. 2008;118:2598 648. 3. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics 2016 update: a report from the American Heart Association. Circulation. 2016;133:e38 360. 4. Krumholz HM, Normand SL, Wang Y. Trends in hospitalizations and out- comes for acute cardiovascular disease and stroke, 1999-2011. Circulation. 2014;130:966 75. 5. Yeh RW, Normand SL, Wang Y, et al. Geographic disparities in the inci- dence and outcomes of hospitalized myocardial infarction: does a rising tide lift all boats? Circ Cardiovasc Qual Outcomes. 2012;5:197 204. 6. Yeh RW, Sidney S, Chandra M, et al. Population trends in the inci- dence and outcomes of acute myocardial infarction. N Engl J Med. 2010;362:2155 65. 7. Wallentin L, Becker RC, BudajA, et al. Ticagrelor versus clopidogrel in pa- tients with acute coronary syndromes. N Engl J Med. 2009;361:1045 57. 8. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myo- cardial infarction. Circulation. 2012;126:2020 35. 9. Roe MT, Parsons LS, Pollack CV Jr, et al. Quality of care by classifica- tion of myocardial infarction: treatment patterns for ST-segment eleva- tion vs non-ST-segment elevation myocardial infarction. Arch Intern Med. 2005;165:1630 6. 10. Mandelzweig L, Battler A, Boyko V, et al. The second Euro Heart Survey on acute coronary syndromes: characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. Eur Heart J. 2006;27:2285 93. 11. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guide- line for the management of patients with non ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344 426. 12. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:529 55. 13. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458 73. 14. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardio- vascular risk in adults: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(suppl 2):S1 45. 15. Levine GN, O'Gara PT, Bates ER, et al. 2015 ACC/AHA/SCAI Focused Update on primary percutaneous coronary intervention for patients with ST- elevation myocardial Infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2016;133:1135 47. 16. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2016;134:e123 55. 17. Yancy CW, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016;134:e282 93. 18. Drozda JP Jr, Ferguson TB Jr, Jneid H, et al. 2015 ACC/AHA focused update of secondary prevention lipid performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes. 2016;9:68 95. 19. Masoudi FA, Bonow RO, Brindis RG, et al. ACC/AHA 2008 statement on performance measurement and reperfusion therapy: a report of the ACC/AHA Task Force on Performance Measures (Work Group to address the challenges of Performance Measurement and Reperfusion Therapy). Circulation. 2008;118:2649 61. 20. Wang TY, Nallamothu BK, Krumholz HM, et al. Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. JAMA. 2011;305:2540 7. 21. Dauerman HL, Bates ER, Kontos MC, et al. Nationwide analysis of patients with ST-segment-elevation myocardial infarction transferred for primary percutaneous intervention: findings from the American Heart Association Mission: Lifeline Program. Circ Cardiovasc Interv. 2015;8:e002450. 22. Jneid H. Cardiac rehabilitation after myocardial infarction: unmet needs and future directions. JAMA Cardiol. 2016;1:978 9. 23. Aragam KG, Dai D, Neely ML, et al. Gaps in referral to cardiac reha- bilitation of patients undergoing percutaneous coronary intervention in the United States. J Am Coll Cardiol. 2015;65:2079 88. 11 24. Bangalore S, Fonarow GC, Peterson ED, et al. Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction. Am J Med. 2012;125:1000 9. 25. Li S, Fonarow GC, Mukamal KJ, et al. Sex and race/ethnicity-related dis- parities in care and outcomes after hospitalization for coronary artery dis- ease among older adults. Circ Cardiovasc Qual Outcomes. 2016;9:S36 44. 26. Normand SL, McNeil BJ, Peterson LE, et al. Eliciting expert opinion us- ing the Delphi technique: identifying performance indicators for cardio- vascular disease. Int J Qual Health Care. 1998;10:247 60. 27. Physician Consortium for Performance Improvement. Tobacco Use: Screening and Cessation Intervention. Available at: https://www.thep- cpi.org/pcpi/media/PCPI-Maintained-Measures/Preventive-Care-and- Screening-Updated-June-2016.pdf. Accessed June 2, 2017. 28. Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services. Circulation. 2010;122:1342 50. 29. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial in- farction. N Engl J Med. 2003;348:1309 21. 30 ISIS-2 (Second International Study of Infarct Survival Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet. 1988;2:349 60. 31. Xian Y, Wang TY, McCoy LA, et al. Association of discharge aspirin dose with outcomes after acute myocardial infarction: insights from the Treatment with ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) study. Circulation. 2015;132:174 81. 32. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocar- dial infarction, and stroke in high risk patients. BMJ. 2002;324:71 86. 33. Mehta SR, Bassand JP, Chrolavicius S, et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med. 2010;363:930 42. 34. Grosser T, Fries S, Lawson JA, et al. Drug resistance and pseudoresis- tance: an unintended consequence of enteric coating aspirin. Circulation. 2013;127:377 85. 35. Barnathan ES, Schwartz JS, Taylor L, et al. Aspirin and dipyridamole in the prevention of acute coronary thrombosis complicating coronary angio- plasty. Circulation. 1987;76:125 34. 36. Jolly SS, Pogue J, Haladyn K, et al. Effects of aspirin dose on ischaemic events and bleeding after percutaneous coronary intervention: insights from the PCI-CURE study. Eur Heart J. 2009;30:900 7. 37. Chen ZM, Jiang LX, Chen YP, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo- controlled trial. Lancet. 2005;366:1607 21. 38. Sabatine MS, Cannon CP, Gibson CM, et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005;352:1179 89. 39. Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and sec- ondary prevention of vascular disease: collaborative meta-analysis of indi- vidual participant data from randomised trials. Lancet. 2009;373:1849 60. 40. Mahaffey KW, Wojdyla DM, Carroll K, et al. Ticagrelor compared with clopidogrel by geographic region in the Platelet Inhibition and Patient Outcomes (PLATO) trial. Circulation. 2011;124:544 54. 41. Mehta SR, Tanguay JF, Eikelboom JW, et al. Double-dose versus stan- dard-dose clopidogrel and high-dose versus low-dose aspirin in individu- als undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet. 2010;376:1233 43. 42. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment el- evation. N Engl J Med. 2001;345:494 502. 43. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/ SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574 651. 44. Popma JJ, Berger P, Ohman EM, et al. Antithrombotic therapy during percutaneous coronary intervention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:576S 99S. 45. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:1329 39. 46. Deleted in proof. 47. Schomig A, Neumann FJ, Kastrati A, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary- artery stents. N Engl J Med. 1996;334:1084 9. 48. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocar- dial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730 7. 49. BHAT Study Investigators. A randomized trial of propranolol in pa- tients with acute myocardial infarction. I. Mortality results. JAMA. 1982;247:1707 14. 50 Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383 9. 51. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coro- nary events after myocardial infarction in patients with average choles- terol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med. 1996;335:1001 9. 52. Wilt TJ, Bloomfield HE, MacDonald R, et al. Effectiveness of statin therapy in adults with coronary heart disease. Arch Intern Med. 2004;164:1427 36. 53. Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more in- tensive lowering of LDL cholesterol: a meta-analysis of data from 170000 participants in 26 randomised trials. Lancet. 2010;376:1670 81. 54. Larsson H, Areskog M, Areskog NH, et al. Should the exercise test (ET) be performed at discharge or one month later after an episode of unsta- ble angina or non-Q-wave myocardial infarction? Int J Card Imaging. 1991;7:7 14. 55. Mahmarian JJ, Shaw LJ, Filipchuk NG, et al. A multinational study to establish the value of early adenosine technetium-99m sestamibi myo- cardial perfusion imaging in identifying a low-risk group for early hos- pital discharge after acute myocardial infarction. J Am Coll Cardiol. 2006;48:2448 57. 56. Nyman I, Larsson H, Areskog M, et al. The predictive value of silent isch- emia at an exercise test before discharge after an episode of unstable coro- nary artery disease. RISC Study Group. Am Heart J. 1992;123:324 31. 57. Starling MR, Crawford MH, Kennedy GT, et al. Treadmill exercise tests predischarge and six weeks post-myocardial infarction to detect abnor- malities of known prognostic value. Ann Intern Med. 1981;94:721 7. 58. Marwick TH, Anderson T, Williams MJ, et al. Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol. 1995;26:335 41. 59. Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocar- dial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med. 1992;327:669 77. 60. Torp-Pedersen C, Kober L. Effect of ACE inhibitor trandolapril on life expectancy of patients with reduced left-ventricular function after acute myocardial infarction. TRACE Study Group. Trandolapril Cardiac Evaluation. Lancet. 1999;354:9 12. 61. ACE inhibitor Myocardial Infarction Collaborative Group. Indications for ACE inhibitors in the early treatment of acute myocardial infarction: systematic overview of individual data from 100000 patients in random- ized trials. ACE Inhibitor Myocardial Infarction Collaborative Group. Circulation. 1998;97:2202 12. 62. Pfeffer MA, McMurray JJ, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med. 2003;349:1893 906. 63. Ball SG, Hall AS, Murray GD. ACE inhibition, atherosclerosis and myo- cardial infarction the AIRE Study in practice. Acute Infarction Ramipril Efficacy Study. Eur Heart J15 suppl B199420 5. 26 30. 64. Kober L, Torp-Pedersen C, Carlsen JE, et al. A clinical trial of the an- giotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group. N Engl J Med. 1995;333:1670 6. 65. Pfeffer MA, Greaves SC, Arnold JM, et al. Early versus delayed angio- tensin-converting enzyme inhibition therapy in acute myocardial infarc- tion: the healing and early afterload reducing therapy trial. Circulation. 1997;95:2643 51. 66. Maggioni AP, Fabbri G. VALIANT (VALsartan In Acute myocardial iN- farcTion) trial. Expert Opin Pharmacother. 2005;6:507 12. 67. Garg R,Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA. 1995;273:1450 6. 68. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting- enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. 12 The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342:145 53. 69. Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547 59. 70. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collabora- tive overview of early mortality and major morbidity results from all ran- domised trials of more than 1000 patients. Lancet. 1994;343:311 22. 71. Boersma E, Maas AC, Deckers JW, et al. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996;348:771 5. 72. Goldberg RJ, Mooradd M, Gurwitz JH, et al. Impact of time to treatment with tissue plasminogen activator on morbidity and mortality following acute myocardial infarction (The second National Registry of Myocardial Infarction). Am J Cardiol. 1998;82:259 64. 73. Milavetz JJ, Giebel DW, Christian TF, et al. Time to therapy and salvage in myocardial infarction. J Am Coll Cardiol. 1998;31:1246 51. 74. Nallamothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol. 2003;92:824 6. 75. Pinto DS, Kirtane AJ, Nallamothu BK, et al. Hospital delays in reperfu- sion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation. 2006;114:2019 25. 76. Chareonthaitawee P, Gibbons RJ, Roberts RS, et al. The impact of time to thrombolytic treatment on outcome in patients with acute myocardial infarction. For the CORE investigators (Collaborative Organisation for RheothRx Evaluation). Heart. 2000;84:142 8. 77. McNamara RL, Herrin J, Wang Y, et al. Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarc- tion. Am J Cardiol. 2007;100:1227 32. 78. Newby LK, Rutsch WR, Califf RM, et al. Time from symptom on- set to treatment and outcomes after thrombolytic therapy. GUSTO-1 Investigators. J Am Coll Cardiol. 1996;27:1646 55. 79. The ISAM Study Group. A prospective trial of intravenous streptokinase in acute myocardial infarction (I.S.A.M.). Mortality, morbidity, and infarct size at 21 days. N Engl J Med. 1986;314:1465 71. 80. Rossi P, Bolognese L. Comparison of intravenous urokinase plus hepa- rin versus heparin alone in acute myocardial infarction. Urochinasi per via Sistemica nell'Infarto Miocardico (USIM) Collaborative Group. Am J Cardiol. 1991;68:585 92. 81. AIMS Trial Study Group. Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo-controlled clinical trial. Lancet. 1988;1:545 9. 82. LATE Study Group. Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6-24 hours after onset of acute myocardial infarction. Lancet. 1993;342:759 66. 83. EMERAS (Estudio Multicentrico Estreptoquinasa Republicas de America del Sur) Collaborative Group. Randomised trial of late throm- bolysis in patients with suspected acute myocardial infarction. Lancet. 1993;342:767 72. 84 Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit coronary lesion in patients presenting with ischemic cardiac pain at rest. Results of the Thrombolysis in Myocardial Ischemia (TIMI IIIA) Trial. Circulation. 1993;87:38 52. 85. 