AHA/ACC Issue New Performance, Quality Measures for MI

Patrice Wendling

September 22, 2017

DALLAS, TX and WASHINGTON, DC — For the first time in nearly a decade, the American College of Cardiology (ACC) and American Heart Association (AHA) have released a new set of performance and quality measures for ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI)[1].

"There was an urgent need to update the 2008 measure set to reflect the current era and new standards of care for treating MI patients," task force writing committee chair Dr Hani Jneid (Baylor College of Medicine, Michael DeBakey VA Medical Center, Houston, TX) told theheart.org | Medscape Cardiology.

He noted that several clinical trials supporting the use of novel therapies and therapeutic strategies have emerged since the last update, as well as new AHA/ACC guidelines to match these changes. They include the 2013 STEMI and 2014 acute coronary syndrome (ACS) guidelines but also the 2013 cholesterol guidelines, which established high-intensity statin use in patients with documented atherosclerotic CV disease as a new standard of care and is reflected in a revised performance measure for acute MI.

The new quality and performance measure set was published September 21, 2017 in the Journal of the American College of Cardiology and copublished in Circulation: Cardiovascular Quality and Outcomes and includes 24 total (17 performance and seven quality) measures. Of these, four performance and seven quality measures are completely new.

The four new performance measures are:

  • Immediate angiography for resuscitated out-of-hospital cardiac arrest in STEMI patients.

  • Noninvasive stress testing before discharge in conservatively treated patients.

  • Early cardiac troponin measurement, within 6 hours of arrival.

  • Participation in a regional or national acute-MI registry.

The seven new quality measures are:

  • Risk-score stratification for NSTEMI patients.

  • Early invasive strategy, within 24 hours, in high-risk NSTEMI patients.

  • Therapeutic hypothermia for comatose STEMI patients with out-of-hospital cardiac arrest.

  • Aldosterone antagonist at discharge.

  • Inappropriate in-hospital use of NSAIDs.

  • Inappropriate prescription of prasugrel (Effient/Lilly/Daiichi-Sankyo) at discharge in patients with a history of prior stroke or TIA.

  • Inappropriate prescription of high-dose aspirin with ticagrelor (Brilinta /Brilique, AstraZeneca) at discharge.

"We aimed to have simple, measurable, and actionable measures, but admittedly many measures had their intricacies and challenges," Jneid said.

The early invasive strategy in high-risk NSTEMI patients, for example, may be challenging because it predominantly reduces recurrent ischemia rather than hard outcomes of recurrent MI or death and creates a logistical burden on cardiac catheterization labs, especially during weekends. In addition, it can be difficult to determine who is high risk because objective stratification by risk scores—now added as a quality measure—is usually not available in current registries, he said.

Another potential implementation challenge is the revised performance measure for P2Y12-receptor inhibitor prescription at discharge for STEMI and NSTEMI patients because the construct is a bit complex, Jneid noted. It includes PCI- and medically treated patients and adds ticagrelor and prasugrel to clopidogrel, the sole P2Y12 inhibitor in the 2008 measure set. But while all three drugs can be used in PCI/stented patients, only clopidogrel and ticagrelor are used in medically treated patients, a setting where roughly one-quarter are currently not being treated despite strong evidence and guideline recommendations.

Finally, aldosterone-antagonist prescription at discharge may be controversial because "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 EPHESUS trial," Jneid said.

Dr Gregg Fonarow (Ronald Reagan University of California Los Angeles Medical Center), chair of the task force on performance measures, said, "The data for aldosterone antagonists at discharge is very strong. It's a class I recommendation in the guidelines, but there was some debate around the challenges of ensuring appropriate monitoring of serum potassium levels and whether there could be recovery in left ventricular ejection fraction. So there was a lot of discussion and consideration as these went to public comment about whether this should be a performance vs a quality measure.

"Ultimately we settled on it being a quality measure, but you could make a case, when there's a 15% to 25% mortality reduction with this agent and there are large gaps in variation, why it wasn't a full-blown performance measure."

Retired from the 2008 set were several measures predominantly focused on excessive initial dosing of heparin, enoxaparin, abciximab, ebtifibatide, and tirofiban, as well as one sunsetting LDL-cholesterol assessment to target statin prescription or dosing, again reflecting the new lipid guidelines.

While the measures are potentially demanding, Jneid said, "Healthcare providers and institutions should strive to implement all these measures. They simply enhance patients' care and outcomes, and I believe they set the new standard of care for heart attack in the beginning of the 22nd century."

Fonarow said, "What they are most helpful for, in my view, is to power the quality-improvement effort. You have accurate, close-to-real-time data on most of the measures to feed back to clinicians so they can judge where the opportunities are to improve."

Commenting for theheart.org | Medscape Cardiology, Dr Frederick Masoudi (University of Colorado, Denver), said in an email that these measures will be useful in supporting efforts to deliver contemporary evidence-based care to patients with MI, but that process measures such as those included in the document—while necessary—aren't necessarily sufficient to attain the highest-quality care.

"Process measures are in many cases 'topped out,' where performance is generally excellent, such as providing aspirin," he said. "Further, process measures apply only to the sometimes-small segments of the population who meet eligibility criteria."

Also, "Patients likely care much less about what treatments they receive and more about the outcomes that their care achieves. For these reasons, we must also focus on valid risk-adjusted measures of patient outcomes as important complements to these measures to optimize the care of patients with MI."

Finally, he added, "With respect to the retired overdosing measures, I am likely to advocate at my institution that we continue surveillance of medication dosing, as this is known to be an area for improvement nationwide."

Jneid reported no relevant financial relationships. Fonarow reports consulting for Amgen, Boston Scientific, Janssen, Johnson & Johnson, Medtronic, Novartis, St Jude Medical, Takeda, the Medicines Company, and ZS Pharma; and research support from Medtronic and Novartis. Disclosures for the coauthors are listed in the paper. Masoudi reports serving as an AHA official and peer reviewer for the measurement set.

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology,follow us on Twitter and Facebook.

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