Sandbox: STEMI

2017 ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting with ST-segment Elevation

What is new in 2017 Guidelines on AMI-STEMI?

2012	2017
IIa - Radial access	I - Radial access (MATRIX)
IIa - DES over BMS	I - DES over BMS (EXAMINATION, COMFORTABLE-AMI, NORSTENT)
III - Complete Revascularization	IIa - Complete Revascularization (PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute)
IIa - Complete Revascularization	III - Thrombus Aspiration (TOTAL, TASTE)
I - Bivalirudin	IIa -Bivalirudin (MATRIX, HEAT-PPCI)
IIb - Enoxaparin	IIa - Enoxaparin (ATOLL, Meta-analysis)
IIb - Early Hospital Discharge	IIa - Early Hospital Discharge (Small trials & observational data)
I - (Oxygen when SaO2 <95%) OXYGEN	I - OXYGEN (Oxygen when SaO2 <90%) AVOID, DETO2X
(Same dose i.V in all patients) TNK-tPA	TNK-tPA (Half dose i.V. in Pts ≥75 years, STREAM)

ACC/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes

STEMI—Immediate Revascularization by PCI

Indication	Appropriate Use Score (1–9)
Revascularization of the Presumed Culprit Artery by PCI (Primary PCI)
Less than or equal to 12 hours from onset of symptoms	A(9)
Onset of symptoms within the prior 12–24 hours AND Severe HF, persistent ischemic symptoms, or hemodynamic or electrical instability present	A (8)
Onset of symptoms within the prior 12–24 hours AND severe HF, persistent ischemic symptoms, or hemodynamic or electrical instability present	M (6)
Successful Treatment of the Culprit Artery by Primary PCI Followed by Immediate Revascularization of 1 or More Nonculprit Arteries During the Same Procedure
Cardiogenic shock persisting after PCI of the presumed culprit artery - PCI or CABG of 1 or more additional vessels	A (8)
Stable patient immediately following PCI of the presumed culprit artery - One or more additional severe stenosis	M (6)
Stable patient immediately following PCI of the presumed culprit artery - One or more additional intermediate (50%–70%) stenoses	M (4)
A = appropriate; CABG = coronary artery bypass graft; HF = heart failure; M = may be appropriate; PCI = percutaneous coronary intervention; R = rarely appropriate; STEMI = ST-segment elevation myocardial infarction. Median Score 7 to 9: Appropriate Care, Median Score 4 to 6: May Be Appropriate Care, Median Score 1 to 3: Rarely Appropriate Care

STEMI—Initial Treatment by Fibrinolytic Therapy

Indication	Appropriate Use Score (1–9)
PCI of the Presumed Culprit Artery After Fibrinolysis
Evidence of failed reperfusion after fibrinolysis (e.g., failure of ST-segment resolution, presence of acute severe HF, ongoing myocardial ischemia, or unstable ventricular arrhythmias)	A (9)
Stable after fibrinolysis AND Asymptomatic (no HF, myocardial ischemia, or unstable ventricular arrhythmias) AND PCI performed 3–24 hours after fibrinolytic therapy	A (7)
Stable after fibrinolysis AND Asymptomatic (no HF, myocardial ischemia, or unstable ventricular arrhythmias) AND PCI >24 hours after onset of STEMI	M (5)
A = appropriate; CABG = coronary artery bypass graft; HF = heart failure; M = may be appropriate; PCI = percutaneous coronary intervention; R = rarely appropriate; STEMI = ST-segment elevation myocardial infarction. Median Score 7 to 9: Appropriate Care, Median Score 4 to 6: May Be Appropriate Care, Median Score 1 to 3: Rarely Appropriate Care

STEMI—Revascularization of Nonculprit Artery During the Initial Hospitalization

Indication	Appropriate Use Score (1–9)
Successful Treatment of the Culprit Artery by Primary PCI or Fibrinolysis Revascularization of 1 or More Nonculprit Arteries During the Same Hospitalisation
Revascularization by PCI or CABG
Evidence of failed reperfusion after fibrinolysis (e.g., failure of ST-segment resolution, presence of acute severe HF, ongoing myocardial ischemia, or unstable ventricular arrhythmias)	A (9)
Spontaneous or easily provoked symptoms of myocardial ischemia - One or more additional severe stenoses	A (8)
Asymptomatic - Findings of ischemia on noninvasive testing - One or more additional severe stenoses	A (7)
Asymptomatic (no additional testing performed) - One or more additional severe stenoses	M (6)
Asymptomatic (no additional testing performed) - One or more additional intermediate stenoses	R (3)
Asymptomatic - One or more additional intermediate (50%–70%) stenoses - FFR performed and ≤0.80	A (7)
A = appropriate; CABG = coronary artery bypass graft; HF = heart failure; M = may be appropriate; PCI = percutaneous coronary intervention; R = rarely appropriate; STEMI = ST-segment elevation myocardial infarction. Median Score 7 to 9: Appropriate Care, Median Score 4 to 6: May Be Appropriate Care, Median Score 1 to 3: Rarely Appropriate Care

AMI-STEMI - 2017 NEW RECOMMENDATIONS

IIa - Additional lipid lowering therapy if LDL >1.8 mmol/L (70 mg/dL) despite on maximum tolerated statins. IMPROVE-IT, FOURIER	IIa - Complete revascularization during index primary PCI in STEMI patients in shock. (Expert opinion)
IIb - 1) Cangrelor if P2Y12 inhibitors have not been given. (CHAMPION) 2) Switch to potent P2Y12 inhibitors 48 hours after fibrinolysis. (Expert opinion) 3) Extend Ticagrelor up to 36 months in high-risk patients. (PEGASUS-TIMI 54) 4) Use of polypill to increase adherence. (FOCUS)
III - Routine use of deferred stenting. DANAMI 3-DEFER

2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction

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, 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 guideline explicitly recommended measuring LVEF. The 2014 AHA/ACC NSTE-ACS guidelines 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. 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).
PM-13	Inpatient	P2Y12 Receptor Inhibitor Prescribed at Discharge	In the 2008 ACC/AHA STEMI/NSTEMI measure set, 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.

Revised STEMI and NSTEMI Measures

	Care Setting	Measure Title	Rationale for Revision of the 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 guideline 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 2013 STEMI and 2014 AHA/ACC NSTE-ACS 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 guideline 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 STEMI and 2014 AHA/ACC NSTE-ACS guidelines, 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 AHA/ACC NSTE-ACS 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 (e.g., 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 guideline 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 guideline 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.
QM-4	Inpatient	Aldosterone Antagonist at Discharge	This measure seeks to implement Class I recommendations in the 2013 ACCF/AHA STEMI and 2014 AHA/ACC NSTE-ACS 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 EPHESUS 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 STEMI and 2014 AHA/ACC NSTE-ACS 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 STEMI and 2014 AHA/ACC NSTE-ACS 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-6	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 STEMI and 2014 AHA/ACC NSTE-ACS 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, U.S. 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.