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ACC, AHA update guidelines for treating MI
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The American College of Cardiology and the American Heart Association have released updated clinical performance and quality measures to benchmark and improve quality of care for adult patients with STEMI and non-STEMI.
“Every 42 seconds, approximately 1 American will suffer an [acute] MI, and the estimated annual incidences of new and recurrent MI events are 550,000 and 200,000 events, respectively,” Hani Jneid, MD, FACC, FAHA, director of interventional cardiology research at Baylor College of Medicine and director of interventional cardiology at the Michael E. DeBakey Medical Center VA Medical Center, Houston, and colleagues wrote. “Fortunately, the rates of hospitalization and 30-day mortality for [acute] MI have been on the decline. This reduction in mortality is likely related to the shift in the pattern of clinical presentation of [acute] MI as well as to improved acute treatments and long-term care.”
However, survivors of acute MI have significant risk for future CV events, recurrent MI, death, HF and stroke.
In the updated report, the committee included 24 total measures: 17 performance measures and seven quality measures, which could be useful for local quality improvement but do not yet have evidence to support use for public reporting or pay-for-performance programs. Eleven of the measures are new to this guideline.
New performance measures
Four new performance measures were added to this guideline based on recent evidence.
First, the guideline committee recommends immediate angiography for resuscitated out-of-hospital cardiac arrest in patients with STEMI based on the 2013 ACC Foundation/AHA STEMI guideline. In addition, cardiac troponin measurement within 6 hours of arrival was added as a performance measure.
Based on two previous guidelines, noninvasive stress testing before discharge in conservatively treated patients was added.
The authors also recommended that patients participate in a regional or national acute MI registry, as this will help track and assess outcomes, complications and quality of care and is supported by evidence.
Additional quality measures
The authors added seven quality measures to this updated guideline, including risk score stratification for non-STEMI, but this was kept as a quality measure as opposed to a performance measure due to the measure feasibility.
The authors also recommend early invasive strategy for high-risk patients with non-STEMI as a quality measure. In addition, for comatose patients with STEMI and out-of-hospital cardiac arrest, the authors recommended therapeutic hypothermia, but suggested it as a quality measure because of newer data that added to the controversy of effectiveness, timing and implementation of the therapy.
The new guidelines also included four quality measures relating to pharmaceuticals:
- aldosterone antagonist at discharge;
- inappropriate in-hospital use of NSAIDs;
- inappropriate prescription of prasugrel at discharge in patients with a history of prior stroke or transient ischemic attack; and
- inappropriate prescription of high-dose aspirin with ticagrelor (Brilinta, AstraZeneca) at discharge.
Updated performance measures
The authors also updated four performance measures to reflect the current data available. Based on the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, they updated the performance measures to include statin use for acute MI.
The “evaluation of left ventricular systolic function” measure has been updated to the evaluation of left ventricular ejection fraction to reflect current guidelines and medication recommendations based on knowledge of LVEF.
The performance measure on cardiac rehabilitation referral no longer accepts patient reasons for the list of measure exceptions.
Based on FDA approvals since the 2008 guidelines, the performance measure of clopidogrel at discharge has been expanded to include ticagrelor and prasugrel (Effient, Daiichi Sankyo/Eli Lilly).
The authors wrote these guidelines will continue to develop as more evidence comes to light.
“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,” the researchers wrote. “While the majority of current measures are binary (for example, yes or no for medication prescription), the next frontier in performance evaluation may be to also to measure doses of prescribed pharmacotherapies and compare them to doses used in randomized trials showing benefit.” by Cassie Homer
Disclosures: Jneid reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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