ARTICLE IN PRESS

Challenges in Implementation of Institutional

Protocols for Patients With Acute Coronary Syndrome
Atman P. Shah, MD*, and Sandeep Nathan, MD, MS

The diagnosis of acute coronary syndrome (ACS) encompasses ST-segment elevation myo-
cardial infarction (STEMI) and non-ST-segment elevation ACS (non-STEMI and unstable
angina). In recent years, there have been improvements in the rates of death, cardiogenic
shock, and recurrent myocardial infarction in patients with ACS, primarily due to the in-
troduction of new pharmacological and interventional therapies, as well as the introduction
of and adherence to new treatment guidelines. However, ACS still represents a consider-
able public health burden. Treatment recommendations for STEMI and non-ST-segment
elevation differ and there is wide variation in practice patterns and adherence among and
within hospitals especially for the latter diagnosis. Adoption of institutional protocols may
help decrease variability and improve quality of care, efficiency, and, ultimately, patient
outcomes. This report discusses the process of developing and implementing institutional
protocols for patients with ACS, from initial medical contact to discharge and
beyond. © 2018 Elsevier Inc. All rights reserved. (Am J Cardiol 2018;■■:■■–■■)

The publication of numerous national guidelines and the
increased use of evidence-based pharmacological and
interventional therapies have accompanied a decrease in rates
of death, cardiogenic shock, and myocardial infarction (MI)
in patients with acute coronary syndrome (ACS).1 However,
ACS continues to represent a substantial public health burden
in the United States, with an inpatient mortality rate of ~10%
and a 30-day readmission rate for cardiovascular-related events
of ~18%.2 An observational analysis from the CRUSADE (Can
Rapid Risk Stratification of Unstable Angina Patients Sup-
press Adverse Outcomes with Early Implementation of the
American College of Cardiology [ACC]/American Heart
Association[AHA] Guidelines) National Quality Improve-
ment Initiative (n = 64,775) found that for every 10% increase
in composite adherence to guideline-recommended treat-
ments, there is a 10% decrease in in-hospital mortality.3
However, there is wide variation in practice patterns and guide-
line adherence among hospitals, patient types, and physician
experience.3 Having guideline-based, multidisciplinary in-
stitutional protocols in place may help decrease this variability
and improve quality of care, efficiency, and, ultimately, patient
outcomes. This study will discuss the process of developing
and implementing institutional protocols for patients with ACS,
from first presentation to discharge and beyond.
Protocol Development and Implementation Process
Although there are numerous guidelines in place to guide
clinicians in their management of patients with ACS, these
are often lengthy documents that may not always be appro-
priate for individual institutions. Therefore, it is important that
Section of Cardiology, Department of Medicine, The University of
Chicago, Chicago, Illinois. Manuscript received January 23, 2018; revised
manuscript received and accepted March 27, 2018.
This study was supported by AstraZeneca (Wilmington, Delaware).
See page •• for disclosure information.
*Corresponding author: Tel: (773) 702-1372; fax: (773) 702-0241.
E-mail address: ashah@bsd.uchicago.edu (A.P. Shah).
each institution has its own protocols for patient care, taking
into account the typical patient flow, treatment time course,
and resource availabilities specific to the institution.
When embarking on the development of a new protocol,
it is important to have a clear goal and to be clear on the steps
and involvement needed for successful implementation
(Figure 1). The essential first steps include gaining institu-
tional support, forming an experienced multidisciplinary team
(MDT), and developing an in-depth understanding of the
disease area.4 Key stakeholders should be identified and be
made aware of the scope of the problem, and the potential
benefits of consistent guideline-based care. For example, im-
provements in ACS-specific quality metrics included in the
Centers for Medicare & Medicaid Services core measures and
Physician Quality Reporting System measures (e.g., all-
cause 30-day readmission rate).5 The MDT should include
representatives from medical practitioners involved in the pa-
tient’s care. For an ACS protocol, this would likely include
cardiologists, emergency department physicians and nurses,
hospitalists, intensivists, primary care physicians, and
pharmacists. It is also recommended to include a senior ad-
ministrator on the MDT.4 Individual members of the MDT
are likely to already have an understanding of the subject area,
but they will be required to gain an in-depth understanding
of optimal care for the patient with ACS, including major
guideline recommendations, available interventions and
medical treatments, risk stratification tools, discharge plan-
ning, and transition of care. Many detailed, evidence-based
guidelines for ACS are currently available that provide a strong
basis for successful protocol development (Table 1).6–15
One of the first tasks of the MDT will be to map the current
ACS patient journey, ensuring that it is a true reflection of the
institution’s current care pathway, and not an idealized flow.
The National Health Service Institute of Innovation and the
Institute for Healthcare Improvement (IHI) provide useful tools
and in-depth information about process mapping. The MDT
can use these to identify gaps between the current level of
care and best practice, and highlight improvement opportunities.

0002-9149/$ - see front matter © 2018 Elsevier Inc. All rights reserved. www.ajconline.org
https://doi.org/10.1016/j.amjcard.2018.03.354
 ARTICLE IN PRESS
2 The American Journal of Cardiology (www.ajconline.org)

Figure 1. Suggested protocol development and implementation process.

Table 1
Acute coronary syndrome guidelines
Guideline Focus

2010 ACCF/ACG/AHA expert consensus document on the concomitant use of proton pump Concomitant use of proton pump
inhibitors and thienopyridines6 inhibitors and thienopyridines
2012 ESC guidelines for the management of acute MI in patients presenting with ST-segment elevation7 STEMI
2013 ACCF/AHA guideline for the management of STEMI8 STEMI
2014 AHA/ACC guideline for the management of patients with NSTE-ACS9 NSTE-ACS
2014 ESC/EACTS guideline for MI revascularization10 MI revascularization
2015 ACC/AHA/SCAI focused update on primary PCI for patients with STEMI11 PCI in STEMI
2015 ESC guideline for the management of acute coronary syndromes in patients presenting NSTE-ACS
without persistent ST-segment elevation12
2015 ILCOR international consensus on cardiopulmonary resuscitation and emergency Pre-hospital and emergency
cardiovascular care science13 department management of ACS
2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with CAD14 Duration of dual antiplatelet therapy
in patients with CAD
2017 ESC guideline for management of acute MI in patients presenting with ST-segment elevation15 STEMI

ACC = American College of Cardiology; ACCF = American College of Cardiology Foundation; ACG = American College of Gastroenterology; ACS =
acute coronary syndrome; AHA = American Heart Association; CAD = coronary artery disease; EACTS = European Association for Cardio-Thoracic Surgery;
ESC = European Society of Cardiology; ILCOR = International Liaison Committee on Resuscitation; MI = myocardial infarction; NSTE-ACS = non-ST-
segment elevation acute coronary syndrome; PCI = percutaneous coronary intervention; SCAI = Society of Cardiovascular Angiography and Interventions;
STEMI = ST-segment elevation myocardial infarction.

The IHI recommends utilizing the model illustrated in
Figure 2 for accelerating improvement in patient care.16 The
model consists of 3 fundamental questions and a plan-do-
study-act (PDSA) cycle. Question 1 prompts the MDT to
establish key aims; these should be time-specific and mea-
surable, and these should define the patient population or
system that will be affected by the improvements (e.g.,
decrease 30-day readmissions by 10% on 1 specified unit).
Question 2 requires the MDT to establish quantitative mea-
sures to determine whether a specific change leads to improved
outcomes. Question 3 encourages the team to select changes;
these can be based on the current gaps, evidence-based guide-
line recommendations, experiences of the practitioners working
in the current system, or experiences from others who have
successfully improved their own institution’s care pathways.
The next step in the IHI model for improvement in-
volves testing the changes in the real-world setting by using
the PDSA cycle. The planned protocol should be imple-
mented on a small scale, the results observed and analyzed,
and the protocol adapted and refined accordingly. This small-
scale PDSA cycle can be performed several times before the
updated, final protocol is implemented on a larger, institution-
wide scale. Once the protocol has been fully implemented,
it is important to perform periodic evaluations and revise when
necessary (e.g., after new guidelines have been published or
new treatments have been made available), with reevalua-
tion after every adjustment.
Along with treatment algorithms and care pathways, in-
stitutional protocols also often include standardized order sets
and discharge tools. The ACS implementation toolkit from
 ARTICLE IN PRESS
Review\/Institutional Protocols for ACS
Figure 2. Institute for Healthcare Improvement model to accelerate
improvement.
the Society of Hospital Medicine recommends that success-
ful protocols should help optimize and standardize the care
delivered, while allowing the clinician to use his or her best
medical judgment to customize care for particular patients
or circumstances. They should also be simple, intuitive, and
reliable, and should try to avoid disrupting the existing work-
flow, wherever possible.17
Essential Elements of Institutional Protocols
Diagnosis and treatment of ACS begins at first medical
contact (FMC). Timely diagnosis is the key to successful man-
agement, and the time between diagnosis and treatment is
predictive of outcome. Before hospitalization is a critical time
point, particularly when the patient is presenting with STEMI,
and municipalities that incorporate a prehospital STEMI system
have seen reductions in the time to diagnosis.18 Dedicated
spoke and hub models of STEMI care facilitate and improve
the care of patients who may present to a hospital capable
of nonpercutaneous coronary intervention.
Diagnosis and initial short-term ischemic and bleeding risk
should be based on a combination of clinical history, symp-
toms, vital signs, other physical findings, electrocardiogram
(ECG), and laboratory results, and are covered extensively
in the available evidence-based guidelines (Table 1). Initial
therapy, including thrombolysis where applicable, can also
be initiated before hospitalization. 7 Delays can and do
occur between FMC and diagnosis, and between FMC and
reperfusion therapy—‘system delay.’ Therefore, the time from
3
Table 2
Factors associated with appropriate selection of management strategy in pa-
tients with non-ST-segment elevation acute coronary syndrome9,12
Preferred Patient characteristics
management strategy
Immediate invasive • Refractory angina pectoris
(<2 hours) • Signs or symptoms of heart failure or new or
worsening mitral regurgitation
• Hemodynamic instability or cardiogenic shock
• Recurrent angina/ischemia at rest or with low-
level activities despite intensive medical therapy
• Sustained ventricular tachycardia or ventricular
fibrillation
Early invasive • Rise or fall in cardiac troponin compatible with
(<24 hours) MI
• Dynamic ST- or T-wave changes (symptomatic or
silent)
• GRACE score >140
Delayed invasive • Diabetes mellitus
(25–72 hours) • Renal insufficiency (GFR <60 ml/min/1.73 m2)
• Reduced LV systolic function (EF <0.40)
• Early post-infarction angina
• PCI within 6 months
• Prior CABG
• GRACE risk score 109–140
• TIMI score ≥2
Ischemia-guided • Low-risk score (e.g. TIMI 0 or 1 or GRACE
<109)
• Low-risk Tn-negative female patients
• Patient or clinician preference in the absence of
high-risk features
CABG = coronary artery bypass graft; EF = ejection fraction; GFR = glo-
merular filtration rate; GRACE = Global Registry of Acute Coronary Events;
LV = left ventricular; MI = myocardial infarction; NSTE-ACS = non-ST-
segment elevation acute coronary syndrome; PCI = percutaneous coronary
intervention; TIMI = Thrombolysis in Myocardial Infarction; Tn, troponin.
FMC to first ECG and the ‘system delay’ are good indices
of the quality of care and predictors of outcomes.7 It is there-
fore recommended that hospitals monitor these delay times
and work to achieve recommended targets.7 To prevent delays,
protocols should include decision-making models and algo-
rithms for risk stratification (see Table 2) of patients presenting
with chest pain. The use of standardized order sets is also
useful at this stage in the care pathway, to help maintain con-
sistent, high quality care.
There is evidence that risk-stratification tools confer ad-
ditional prognostic value beyond clinical assessment alone,
and can be used to inform therapeutic decision-making and
help improve communication between healthcare providers
from differing areas of clinical expertise. These tools may also
be particularly useful in patients with atypical symptoms, such
as patients with low elevation of their initial troponin level.
It should be noted that whereas the value of risk scores has
been clearly elucidated, their impact on patient outcomes has
not yet been adequately investigated.12 Available risk scores
include the History, ECG, Age, Risk factors, and Troponin
(HEART) score,19 the Thrombolysis In Myocardial Infarc-
tion (TIMI) score,20 and the Global Registry of Acute Coronary
Events (GRACE) risk score.21,22
The 2015 European Society of Cardiology (ESC) guide-
line for the management of ACS in patients without persistent
 ARTICLE IN PRESS
4 The American Journal of Cardiology (www.ajconline.org)
ST-segment elevation acknowledges that the TIMI score
is simple to use, but that the GRACE risk score provides
the most accurate stratification of risk both on admission
and at discharge. The GRACE 2.0 risk calculator (http://
www.gracescore.org/WebSite/default.aspx?ReturnUrl=%2f)
provides a direct estimation of in-hospital, 6-month, 1-year,
and 3-year mortality and relies more heavily than other scoring
systems on dynamic clinical variables ascertained at the time
of presentation, rather than historical variables.23
The CRUSADE bleeding risk score can be considered in
patients who underwent coronary angiography (http://www
.crusadebleedingscore.org).12 This risk score estimates the like-
lihood of an in-hospital major bleeding event. Other bleeding
risk scores are available (e.g., HAS-BLED, ATRIA, and
ORBIT) and clinicians are encouraged to employ a bleed
scoring system in patients with ACS and a concomitant need
for anticoagulation.
Comprehensive care pathways and treatment algorithms
are integral components of institutional protocols. These al-
gorithms should guide the selection of management strategy
and early hospital care, including oxygen administration, ni-
trates, analgesic therapy, β blockers, and calcium channel
blockers. They should also guide platelet inhibition, antico-
agulation, and cholesterol management, and the management
of acute bleeding events. The National Institute for Health
and Care Excellence has developed a comprehensive care
pathway for patients presenting with chest pain, from pre-
sentation and initial diagnostic tests to treatment/management
options (https://pathways.nice.org.uk/pathways/chest-pain).
In patients without a clear management pathway (e.g., pa-
tients without a classic presentation or in whom comorbid
conditions preclude accurate history or clinical assess-
ment), treatment algorithms are invaluable in ensuring that
the right medications are administered to the right patients
as soon as they are required.24
For patients with the clinical presentation of STEMI, early
mechanical or pharmacological reperfusion should be per-
formed as early as possible.7 However, in patients with NSTE-
ACS, determining whether to pursue an early invasive or initial
conservative management plan is a vital initial consider-
ation. The 2014 AHA/ACC and 2015 ESC guidelines provide
recommendations on the preferred management strategy in
patients with NSTE-ACS based on a patient’s clinical
characteristics and clinical risk (Table 2).9,12 In both strate-
gies, patients should receive optimal anti-ischemic and
antithrombotic medical therapy.9,12 The duration of dual
antiplatelet therapy and the choice of P2Y12 receptor antago-
nist should be made based on the individual patient’s ischemic
and bleeding risk, as well as the probability of percutaneous
coronary intervention for treatment of the index event. A
summary of key guideline recommendations pertaining to the
use of antiplatelet agents is summarized in Table 3.
Careful and consistent transitioning of care among emer-
gency medical services, emergency departments, catheterization
laboratories, and hospital wards and the transition to outpa-
tient care at hospital discharge are vital components of
institutional protocols.24 Timely and accurate communica-
tion between departments is essential for safe transition
of patients, reducing loss of vital patient information and
pending care plan changes and maintaining the continuum
of care.25
To avoid delays and optimize continuity of care, dis-
charge planning should be initiated soon after admission.4
Many tools are available to facilitate transitions. One of these
tools is the Re-Engineered Discharge toolkit, which con-
sists of 12 actions and can be used in all patients, irrespective
of condition/illness, and has been shown to reduce readmis-
sion and posthospital emergency department visits.26 The
Better Outcomes by Optimizing Safe Transitions Care Tran-
sitions implementation toolkit aims to reduce unnecessary
readmissions and improve transitions of care by enabling teams
to redesign hospital discharge workflow.27 Finally, the modi-
fiable ACS transitions tool developed by the Society of
Hospital Medicine includes discharge preparation checklists,
personal health records, and transition coach charting forms.28
All of these tools may be enhanced, and the overall process
improved with the integration of these orders and measures
into an electronic medical record system. Within the con-
struct of a particular healthcare system, the electronic medical
record will also facilitate data gathering and distribution.
Timely and frequent outpatient follow-up is significantly
and independently associated with lower readmission rates.29
Before discharge, a face-to-face visit should be scheduled for
48 to 72 hours after discharge for high-risk patients, within
7 days for moderate-risk patients, and as deemed medically
reasonable by the physician for low-risk patients. Tele-
phone follow-up calls, conducted by hospital providers or the
healthcare community, are crucial in reinforcing a patient’s
care plan and identifying potential issues.
A policy to improve medication adherence within the pro-
tocol is beneficial, especially during the highest risk period
of stent thrombosis.24 The Reduction of Atherothrombosis for
Continued Health registry documented that after the first 12
months after an MI, the rate of ischemic risk continually in-
creases by ~4% per year for the next 4 years,30 so the adoption
of healthier lifestyles and aggressive treatment of modifi-
able risk factors (such as dyslipidemia and hypertension)
should be promoted during posthospital follow-up, and should
be maintained for a long term.
Performance Measures
As the new protocol is implemented, it is vital to assess
whether the changes made are leading to the desired outcomes.4
Time-specific, actionable, and measurable aims, and quan-
titative measures to determine whether the changes made have
led to improved outcomes, should be carefully defined at the
initiation of the protocol development process. Both the ACC/
AHA and ESC guidelines strongly encourage continuous
monitoring of performance indicators to enhance the quality
of and reduce variation in evidence-based care.9,12,15 Re-
cently, the Acute Cardiovascular Care Association of the ESC
stressed the importance of incorporating primary and sec-
ondary quality indicators.31
The quality indicators for acute MI developed by the Acute
Cardiovascular Care Association can be used (Table 4).31 Par-
ticipation in a standardized quality-of-care data registry, to
measure outcomes, complications, and performance mea-
sures, is also recommended. This aspect of the process can
be particularly challenging, especially when institutions are
faced with data that are less than positive. In the ideal situation,
this would be a cause for continued collaboration and
improvement.
 ARTICLE IN PRESS
Review\/Institutional Protocols for ACS 5

Table 3
Summary of key guideline recommendations surrounding platelet inhibition after an acute coronary syndrome
Guideline
2015 ESC guideline for the management
of acute coronary syndromes in
patients presenting without persistent
ST-segment elevation
2012 ESC guideline for the management
of acute MI in patients presenting with
ST-segment elevation
2013 ACCF/AHA guideline for the
management of STEMI
2014 AHA/ACC guideline for the
management of patients with
NSTE-ACS
2014 ESC/EACTS guideline on
myocardial revascularization
2016 ACC/AHA guideline focused update
on duration of dual antiplatelet therapy
in patients with CAD
2017 ESC guideline for management of
acute MI in patients presenting with
ST-segment elevation
Recommendation
• All - Indefinite administration of aspirin
• All - P2Y12 inhibitor plus aspirin for 12 months (unless contraindicated)
- Ticagrelor - patients at moderate to high ischemic risk, regardless of initial treatment strategy
- Prasugrel - patients who are proceeding to PCI (unless contraindicated)
- Clopidogrel - patients who cannot receive ticagrelor or prasugrel or require oral anticoagulation
• Consider dual antiplatelet therapy for 3–6 months after DES implantation in patients at high bleeding risk
• Consider dual antiplatelet therapy >1 year after careful assessment of the ischemic and bleeding risks of
the patient
• Patients undergoing primary PCI - aspirin plus P2Y12 inhibitor (prasugrel or ticagrelor), as early as
possible before angiography, and a parenteral anticoagulant
• Patients undergoing primary PCI - loading dose of aspirin before procedure; daily maintenance dose
continued indefinitely
• Patients receiving a BMS or DES - loading dose of a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor)
given as early as possible; maintenance dose for ≥12 months
• Patients receiving fibrinolytic therapy – continue aspirin indefinitely; administer clopidogrel for >14 days
and ≤12 months
• All patients with NSTE-ACS - aspirin (unless contraindicated, then use clopidogrel) as soon as possible
after presentation; maintain indefinitely
• All patients with NSTE-ACS - P2Y12 inhibitor (clopidogrel or ticagrelor) ≥ 12 months (unless
contraindicated) who are treated with either an early invasive or ischemia-guided strategy
• Patients with NSTE-ACS treated with an early invasive strategy and dual antiplatelet therapy with
intermediate-/high-risk features – consider GP IIb/IIIa inhibitor as part of initial antiplatelet therapy
• Patients with NSTE-ACS undergoing PCI - aspirin (unless contraindicated)
• Add P2Y12 inhibitor to aspirin for ≥12 months (unless contraindicated)
- Prasugrel - patients who are proceeding to PCI (unless contraindicated)
- Ticagrelor - for patients at moderate to high ischemic risk, regardless of initial treatment strategy
- Clopidogrel - for patients when prasugrel or ticagrelor is not available or is contraindicated
• Consider GP IIb/IIIa antagonists for bail-out situations or thrombotic complications
• Patients with ACS treated with PCI - P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) for ≥12
months
• Patients with ACS treated with coronary stent implantation who have tolerated dual antiplatelet therapy
without a bleeding complication and who are not at high bleeding risk - continuation of dual antiplatelet
therapy >12 months may be reasonable
• Patients with ACS treated with dual antiplatelet therapy after DES implantation who develop a high risk
of bleeding, are at high risk of a severe bleeding complication, or develop significant overt bleeding -
discontinuation of P2Y12 inhibitor therapy after 6 months may be reasonable
• Administer aspirin indefinitely
• Low dose (75–100 mg) is indicated
• Add ticagrelor or prasugrel (or clopidogrel if not available or contraindicated) to aspirin for ≥12 months
after PCI (unless contraindicated)
• Patients with high risk of severe bleeding – consider stopping P2Y12 after 6 months
• STEMI patients with stent implantation – consider oral anticoagulation triple therapy for 1–6 months
• Patients who did not undergo PCI – consider dual antiplatelet therapy for 12 months (unless
contraindicated)

ACC = American College of Cardiology; ACCF = American College of Cardiology Foundation; ACS = acute coronary syndrome; AHA = American Heart
Association; BMS = bare-metal stent; CAD = coronary artery disease; DES = drug-eluting stent; EACTS = European Association for Cardio-Thoracic Surgery;
ESC = European Society of Cardiology; GP = glycoprotein; MI = myocardial infarction; NSTE-ACS = non-ST-segment elevation acute coronary syndrome;
PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.

Summary minimize disruptions to the existing workflow and allow cli-

Guideline-based, multidisciplinary institutional proto-
cols can decrease variability in patient care and adherence
to guideline recommendations, and can improve quality of
care and patient outcomes. The establishment of institu-
tional protocols is of specific benefit in ACS—an area with
large patient volumes, high morbidity and mortality rates,
significant variability in treatment strategy, and multiple core
measures and publicly reported outcomes. Although these pro-
tocols aim to optimize and standardize patient care, they should
nicians to use their best judgment.
Acknowledgment: Medical writing support was provided by
Alex Mellors, BSc, of Prime, Knutsford, Cheshire, United
Kingdom, under the direction of the authors and in accordance
with Good Publication Practice guidelines (http://annals
.org/aim/fullarticle/2424869/good-publication-practice
-communicating-company-sponsored-medical-research
-gpp3).
 ARTICLE IN PRESS
6 The American Journal of Cardiology (www.ajconline.org)

Table 4
Recommended main quality indicators for improving the standards of care in myocardial infarction31
Domain of care Main quality indicator
Center organization Center should be part of a network organization with written protocols for rapid and efficient management covering:
• Single emergency phone number of the patient to be connected to a medical system for triage
• Pre-hospital interpretation of ECG for diagnosis and decision for immediate transfer to a center with catheterization laboratory
facilities, bypassing the emergency department
• Pre-hospital activation of the catheterization laboratory
Reperfusion invasive 1. Proportion of STEMI patients reperfused among eligible (onset of symptoms to diagnosis <12 hours)
strategy 2. Proportion of patients with timely reperfusion, defined as:
• Patients with fibrinolysis: < 30 minutes from FMC to needle
• Patients with primary PCI and admitted to centers with catheterization laboratory: < 60 minutes from door to arterial access for
reperfusion with PCI
• Transferred patients: door-in door-out time of <30 minutes

In-hospital risk 1. Proportion of patients with NSTEMI who have ischemic risk assessment using the GRACE risk score. GRACE risk score
assessment should be assessed and the numerical value of the score recorded for all patients
2. Proportion of patients admitted with STEMI and NSTEMI who have bleeding risk assessment using the CRUSADE bleeding
score. The CRUSADE bleeding score should be assessed and the numerical value recorded for all patients
3. Proportion of patients with STEMI and NSTEMI who have assessment of left ventricular ejection fraction. Left ventricular
ejection fraction should be assessed and the numerical value recorded for all patients
Anti-thrombotics during 1. Proportion of patients with “adequate P2Y12 inhibition”, defined as: number of patients discharged with prasugrel or ticagrelor
hospitalization or clopidogrel / patients eligible:
• Ticagrelor: AMI patients without previous hemorrhagic or ischemic stroke, high bleeding risk, fibrinolysis or oral anticoagulation
• Prasugrel: PCI treated AMI patients without previous hemorrhagic or ischemic stroke, high bleeding risk, fibrinolysis or oral
anticoagulation
• Clopidogrel: no indication for prasugrel or ticagrelor and no high bleeding risk
2. Proportion of patients with NSTEMI treated with fondaparinux, unless candidates for immediate (≤2 hours) invasive strategy or
with eGFR ≥20 ml/min
Secondary prevention Proportion of patients with AMI discharge on statins, unless contraindicated, at high intensity (atorvastatin ≥40 mg or rosuvastatin
discharge treatment ≥20 mg)
Patient satisfaction Feedback regarding the patient’s experience is systematically collected for all patients, including:
• Pain control
• Explanations provided by doctors and nurses
• Discharge information regarding what to do in case of recurrence of symptoms and recommendation to attend a cardiac
rehabilitation program
Composite and outcome • Opportunity based composite quality index, with the following individual indicators:
quality index • Center is part of a network organization
• Proportion of patients reperfused among eligible
• Coronary angiography in STEMI and NSTEMI patients at high ischemic risk and without contraindications
• Ischemic risk assessment using the GRACE risk score in NSTEMI patients
• Bleeding risk assessment using the CRUSADE risk score in STEMI and NSTEMI patients
• Assessment of left ventricular ejection fraction before discharge
• Low dose aspirin (unless high bleeding risk or oral anticoagulation)
• Adequate P2Y12 inhibition (unless contraindicated)
• ACE inhibitor (or ARB if intolerant) in patients with clinical evidence of heart failure or a left ventricular ejection fraction ≤0.4
• Beta-blockers (unless contraindicated) in patient with clinical evidence of heart failure of a left ventricular ejection fraction ≤0.4
• High intensity statins
• Feedback regarding the patient’s experience and quality of care is systematically collected for all patients

ACE = angiotensin-converting enzyme; AMI = acute myocardial infarction; ARB = angiotensin receptor blocker; ECG = electrocardiogram; eGFR = es-
timated glomerular filtration rate; FMC = first medical contact; NSTEMI = non-ST segment elevation myocardial infarction; PCI = percutaneous coronary
intervention; STEMI = ST segment elevation myocardial infarction.

Disclosures and heart failure in acute coronary syndromes, 1999–2006. JAMA

The ultimate responsibility for opinions, conclusions, and
data interpretation lies with the authors. Atman P. Shah, MD,
is a consultant and a member of the Speakers Bureau of Astra
Zeneca. The remaining authors have no conflicts of interest
to disclose.
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