New Performance and Quality Metrics for STEMI and NSTEMI Care

The American Heart Association (AHA) and American College of Cardiology (ACC) have issued new performance and quality measures for the treatment of patients with STEMI and NSTEMI, abandoning some previous metrics, revising others, and adopting new ones altogether.

The societies no longer recommend physicians counsel patients on quitting smoking or require the assessment of LDL cholesterol levels. Retiring the assessment of LDL cholesterol levels is in keeping with the latest 2013 lipid guidelines, which no longer require LDL measurements for statin prescription and/or dosing, according to the authors of the new STEMI/NSTEMI performance and quality measures. 

Eliminating counseling for smoking cessation, however, generated a fair amount of discussion amongst the writing committee, according to chair Hani Jneid, MD (Baylor College of Medicine/Michael DeBakey VA Medical Center, Houston, TX).

“Some of the retired measures were based on a lot of research work and generated animated debates among the committee members,” he told TCTMD. “The multifaceted and hard-working committee members had to vote on more than one occasion on these measures. I would say the retirement of the performance measure for smoking cessation counseling has generated the most debate.”

The reason for retiring the inpatient measure of advising patients to quit smoking is that “perfect scores” are consistently achieved and the performance metric appears to be “topped out,” said Jneid. With limited room for further improvement, the AHA/ACC writing committee believes retiring it will allow healthcare providers and institutions to focus on other measures where there is room to get better.

“Notably, there will be a separate CAD outpatient performance measure document which will likely tackle the tobacco cessation measure,” said Jneid. Also, the new performance/quality metrics are considered a “live document,” he said, and subject to future revisions and updates. “So, if a rebound effect is observed—less tobacco cessation counseling occurring in-hospital after acute MI—after retiring this measure, consideration will certainly be given to reinstitute this measure when needed.”

The AHA/ACC are also retiring metrics concerning excessive initial dosing of heparin, enoxaparin, abciximab, eptifibatide, and tirofiban because those measures covered just one aspect of medication use (overdosing) and missed other aspects, such as underdosing and inappropriate use.

Ajay Kirtane, MD (Columbia University Medical Center, New York, NY), who was not involved in drafting the new metrics, told TCTMD that use of measures to capture high-standard care in STEMI/NSTEMI is extremely challenging, a fact highlighted by the decision to drop counseling on smoking cessation in 2017.  

“It jumps right out at you,” he said. “The reason why they dropped it is because perfect scores are being achieved and it’s reached a ceiling. And yet, just empirically, do you really think every hospital patient with myocardial infarction is being effectively counseled on how to stop smoking? I don’t think so. As a result, it shows you just how hard it is to measure some of these things. I don’t want to single one measure out but it does show you how hard it is to actually measure quality at the level of individual hospitals.”

Even if hospitals are able to implement the various performance and quality measures, they likely have to “go above and beyond” to implement local-level quality, said Kirtane.

Revised and Added

Under the revised STEMI and NSTEMI measures—published online September 21, 2017, ahead of print in the Journal of the American College of Cardiology—statin therapy, particularly high-intensity statin therapy for patients with acute MI, is now a performance measure, as is the evaluation of left ventricular ejection fraction (as opposed to the evaluation of left ventricular systolic function). The writing group also revised the performance metric to recommend a P2Y12 receptor inhibitor at discharge rather than simply recommending clopidogrel.

With the availability of three drugs—clopidogrel, prasugrel, and ticagrelor—use of P2Y12 inhibitors on top of aspirin will prevent recurrent MI, said Jneid. Ticagrelor, he noted, also reduced mortality when compared with clopidogrel in the PLATO trial. “These benefits will involve the patients who are treated with coronary intervention and stents as well as medically-treated heart attack patients, although the types of P2Y12 receptor inhibitor used in each of these two settings will differ,” said Jneid.

In total, the AHA/ACC committee introduced four new performance measures and six quality metrics for the treatment of patients with STEMI/NSTEMI. The performance measures include immediate angiography for resuscitated out-of-hospital cardiac arrest patients with STEMI, noninvasive stress testing before discharge in conservatively treated patients, early cardiac troponin measurements (within 6 hours of hospital arrival), and participation in a regional or national acute MI registry.

“Participation in a regional or national registry of AMI is a new measure that I personally strongly believe in, as it has been shown to improve patients’ outcomes and care,” said Jneid.

To TCTMD, Kirtane noted that noninvasive stress testing in conservatively managed patients can sometimes occur after discharge, depending on the hospital. While he agrees with angiography for STEMI patients with out-of-hospital cardiac arrest, timing can sometimes be a challenge. Some patients might have ST elevations that come down again over time while some arrest patients might be acidotic, which results in an ECG which looks hyperkalemic and is often mistaken for STEMI. Those patients, he noted, wouldn’t necessarily need to go to the cath lab.

“Some of these are not so cut and dry,” he said. “I think it just reemphasizes the challenges of measuring quality and performance.”   

The six new quality metrics include risk stratification for NSTEMI patients, early invasive treatment (within 24 hours) in high-risk NSTEMI patients, therapeutic hypothermia for comatose STEMI patients with out-of-hospital cardiac arrest, prescription of an aldosterone antagonist at discharge, avoiding the use of NSAIDs, avoiding prasugrel in patients with a history of stroke or TIA, and avoiding high-dose aspirin with ticagrelor at discharge.  

Since 2008, when the AHA and ACC last published a performance measure set for STEMI/NSTEMI care, numerous clinical trials have emerged to shape clinical practice, said Jneid. These include studies such as PLATO, TRITON-TIMI 38 with prasugrel, and TIMACS, a study that showed the benefit of an early invasive strategy in high-risk STEMI patients. Additionally, new guidelines have since been published, including those for the treatment of cholesterol and the management of patients with NSTE ACS. 

“These performance measures and quality metrics are driven by scientific evidence from robust clinical trials and are also definite recommendations by the ACC and AHA guidelines,” said Jneid.  “Overall, monitoring and implementing these measures will undoubtedly enhance care and outcome of patients, and this is the ultimate goal of this work,” he added.

Regulatory agencies in the United States may use some of the performance metrics and tie them to pay-for-performance or they may be used in public reporting efforts at the state level. Quality metrics, on the other hand, are used for local quality improvement but are not considered appropriate for public reporting or pay-for-performance.