New AHA/ACC Performance, Quality Metrics for Coronary Revascularization

Megan Brooks

August 03, 2023

The American Heart Association (AHA) and American College of Cardiology (ACC), in collaboration with several other professional organizations, have published the first comprehensive set of performance and quality measures specific for coronary artery revascularization.

"Performance measures are helpful to accelerate translation of scientific evidence into clinical practice and are intended to provide practitioners and institutions with tools to measure the quality of care provided and identify opportunities for improvement," writing group chair Gregory J. Dehmer, MD, Carilion Clinic Cardiology, Roanoke, Virginia, told | Medscape Cardiology.

Performance measures are "evidence-based, have exceptions and exclusions supported by evidence and should be actionable," Dehmer added. They typically target meaningful gaps in the quality of care and are based on Class 1 clinical practice guidelines.

The 44-page document was published online July 27 in the Journal of the American College of Cardiology.

Topics addressed in the 15 performance measures include:

  • The importance of using coronary physiological measurements rather than visual assessment of an intermediate severity lesion;.

  • Dual antiplatelet therapy (DAPT) with percutaneous coronary intervention (PCI), as a "cornerstone" of therapy for prevention of thrombotic complications and reduction of ischemic events;

  • Antiplatelets and anticoagulation after PCI, which provide "an important outcome benefit" and represent "an existing gap in care," especially in patients with atrial fibrillation (AF); and

  • P2Y12 inhibitors with fibrinolytic therapy to reduce recurrent ischemia and avoid increased risk of bleeding relative to aspirin.

Other performance measures address aspirin in patients undergoing coronary artery bypass grafting (CABG), lipid management, glycemic control during and after CABG, use of internal mammary artery for CABG, arterial access for PCI, noninfarct artery revascularization in ST-segment elevation myocardial infarction (STEMI), noninfarct artery PCI in STEMI with shock, management of ventricular arrhythmias, and referral to cardiac rehabilitation from inpatient and outpatient settings.

"The measures are structured in a typical format with the goal to seek a higher performance score, ideally nearing 100%," Dehmer told | Medscape Cardiology.

The document also includes five quality measures. These measures are "important but are not based on Class 1 clinical practice guidelines or are lacking in other important characteristics (eg, questions of feasibility, validity)," the writing group notes.

"If additional evidence supports the importance of the proposed quality measures, they may be changed to performance measures in the future," they point out.

The quality measures emphasize shared decision-making and informed consent; periprocedural hydration in cardiovascular angiography; smoking cessation after revascularization; risk assessment before CABG; and reduction of AF after CABG.

The document also includes two structural measures. One focuses on preprocedural assessment and fostering collaborative efforts among cardiovascular specialists, and the other encourages registry participation to measure performance.

Areas for Future Research

The writing group notes that the field of coronary artery revascularization "continues to evolve rapidly."

They say areas for further research include determining the optimal role and timing for revascularization in cardiogenic shock, research on conduits and techniques for CABG, the use of mechanical support for high-risk PCI, defining the role of drug-coated balloons, and the optimal duration of antiplatelet therapy after PCI and in the setting of AF.

New devices for PCI continue to enter the marketplace, and research is needed to better define their safety and effectiveness in real-world populations, they add.

Chronic total occlusions are another area in need of additional research.

"Whereas many chronic total occlusions were once thought too difficult to treat, newer techniques for the recanalization of these vessels are being developed, but more research is needed to determine the role of chronic total occlusion therapies on long-term outcomes such as death, heart failure events, and optimal case selection," the writing group points out.

They also note that several studies have shown that an initial strategy of guideline-directed medical therapy alone, compared with guideline-directed medical therapy plus revascularization, in selected patients with chronic coronary disease has similar effects on cardiovascular outcomes such as death, MI, heart failure, and hospitalization for unstable angina.

More investigation is needed to compare the long-term effects of these two therapies and identify subgroups of stable patients that may have a mortality benefit from early revascularization as well as the effects of these two therapeutic strategies on symptoms and quality of life.

More research is also needed to identify gender-based differences in responses to available therapies.

The document was developed in collaboration with the American Association for Thoracic Surgery (AATS) and the Society for Cardiovascular Angiography and Interventions (SCAI).

It has been endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Society for Preventive Cardiology, American Society of Health-System Pharmacists, Association of Black Cardiologists, Heart Failure Society of America, Heart Rhythm Society, International Society for Heart and Lung Transplantation, Outpatient Endovascular and Interventional Society, and the Preventive Cardiovascular Nurses Association.

This research had no commercial funding. Dehmer has disclosed no relevant financial relationships.

J Am Coll Cardiol. Published online July 27, 2023. Abstract

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