AHA/ACC Issue New Performance, Quality Measures for Chronic Coronary Disease

The American Heart Association and American College of Cardiology (AHA/ACC) have teamed up to fine-tune performance and quality measures for chronic coronary disease, publishing their recommendations online in the Journal of the American College of Cardiology.

Writing group chair Marlene S. Williams, MD (Johns Hopkins Bayview Medical Center, Baltimore, MD), said the goal was to update the measures to reflect the latest trial evidence and to tease out advice from existing clinical guidance in a digestible format “that is implementable and is reasonable.”

For patients with chronic coronary disease, “the  landscape is changing as we advance care,” Williams told TCTMD. The document is meant to “help spread the word and really allow [clinicians] to know how we should we be managing our patients now. It can be intimidating to say, well, this changes and that changes and this changes” without knowing what to prioritize amid all the various sources of information.

It’s helpful, said Williams, “to be able to see what should we be focusing on and what issues are moving the needle as it relates to reducing mortality and complications and advancing care.”

Cardiologists are not the only intended audience, she stressed. “There are a lot of primary care providers that are . . . doing a large amount of this clinical care on their own or within internal medicine groups. [These physicians] see these patients on the front line and really manage these things, in many cases without cardiovascular support, and they’re doing a great job.”

Clinical Takeaways

Together, the authors came up with 10 performance measures and three quality measures for the management of chronic coronary disease in the outpatient setting. Informing the effort were the 2023 guidelines for chronic coronary disease, 2023 performance measures for coronary artery revascularization, 2019 performance measures for high blood pressure, 2018 cholesterol guidelines, and 2011 CAD/hypertension performance measures.

The 10 performance measures include:

• Tobacco use screening and cessation counseling
• Antiplatelet therapy without anticoagulation
• Lipid measurement
• High-intensity statin therapy
• Blood pressure control (< 130/80 mm Hg)
• Beta-blockers in patients with LVEF ≤ 40%
• ACE inhibitor/ARB therapy in patients with hypertension, diabetes, LVEF ≤ 40%, or chronic kidney disease
• Avoidance of routine periodic testing (invasive and noninvasive) in stable patients
• Referral to cardiac rehabilitation

The three quality measures relate to imaging, lipid management, and patient education on symptom management and lifestyle modification.

An area where there is a change to prior documents is the role of aspirin, Williams highlighted. “There’s more and more evidence to suggest that P2Y12 inhibitors are equivalent and certainly not inferior to aspirin therapy in patients with chronic coronary disease.” Trials such as HOST-EXAM and STOPDAPT-2, for instance, have explored what type of antiplatelet therapy is best and how long that therapy should last.

One topic likely to generate discussion, Williams said, is the advice to avoid routine periodic testing—for example, stress testing or cardiac catheterization when there’s no other reason to dig deeper. “That is not what we should be doing in patients who are stable, no change in their ejection fraction, no change in symptoms,” she emphasized. This unnecessary testing doesn’t benefit patients and, in some cases, can result in complications, said Williams.

Data informing this performance measure come from the POST-PCI and ReACT trials, among others.

Future research, Williams and colleagues say, should clarify the best way to de-escalate dual antiplatelet therapy after PCI, the ideal antiplatelet regimen for secondary prevention, LDL cholesterol targets for chronic coronary disease, how to measure ambulatory blood pressure, and how to individualize management based on genetic and phenotypic characteristics.

The AHA/ACC document was created in collaboration with the American College of Clinical Pharmacy, American Society for Preventive Cardiology, Preventive Cardiovascular Nurses Association, and Society for Cardiovascular Angiography and Interventions. It also was endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Society of Nuclear Cardiology, Association of Black Cardiologists, and Society for Cardiovascular Magnetic Resonance.