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ACC/AHA STEMI/NSTEMI PERFORMANCE MEASURES

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

A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures on ST-Elevation and Non–ST-Elevation Myocardial Infarction)

Harlan M. Krumholz, MD, FACC, FAHA, Chair, WRITING COMMITTEE MEMBERS, Jeffrey L. Anderson, MD, FACC, FAHA, WRITING COMMITTEE MEMBERS, Neil H. Brooks, MD, FAAFP, WRITING COMMITTEE MEMBERS, Francis M. Fesmire, MD, FACEP, WRITING COMMITTEE MEMBERS, Costas T. Lambrew, MD, MACC, WRITING COMMITTEE MEMBERS, Mary Beth Landrum, PhD, WRITING COMMITTEE MEMBERS, W. Douglas Weaver, MD, FACC, FAHA, WRITING COMMITTEE MEMBERS, John Whyte, MD, MPH, WRITING COMMITTEE MEMBERS, Robert O. Bonow, MD, FACC, FAHA, Chair, TASK FORCE MEMBERS, Susan J. Bennett, DNSC, RN, FAAN, FAHA, TASK FORCE MEMBERS, Gregory Burke, MD, MS, FAHA, TASK FORCE MEMBERS, Kim A. Eagle, MD, FACC, FAHA, Chair, TASK FORCE MEMBERS^_*, Harlan M. Krumholz, MD, FACC, FAHA, TASK FORCE MEMBERS, Costas T. Lambrew, MD, MACC, TASK FORCE MEMBERS, Jane Linderbaum, NP, TASK FORCE MEMBERS, Frederick A. Masoudi, MD, FACC, FAHA, TASK FORCE MEMBERS, Sharon-Lise T. Normand, PhD, MSc, FACC, TASK FORCE MEMBERS, Ileana L. PiÑa, MD, FACC, TASK FORCE MEMBERS, Martha J. Radford, MD, FACC, FAHA, TASK FORCE MEMBERS, John S. Rumsfeld, MD, PhD, FACC, TASK FORCE MEMBERS, James L. Ritchie, MD, FACC, TASK FORCE MEMBERS and John A. Spertus, MD, MPH, FACC, TASK FORCE MEMBERS

	Table of Contents

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

I Introduction......239

A Scope of the Problem......239

B Writing Committee Structure/Members......239

C Independence/Relationships With Industry Disclosure......239

D Review/Endorsement......239

II Methodology......239

A Definition of STEMI/NSTEMI......239

B Dimensions of Care......240

C Literature Review......240

D Definition and Selection of Measures......240

III STEMI/NSTEMI Performance Measures......241

A Inpatient Population and Care Period......241

B Brief Summary of the Measurement Set......241

C Data Collection......242

IV Discussion......242

A Addition of ARBs to ACEI Measure......242

B Median Versus Mean—Time to Fibrinolytic Therapy and Time to Primary PCI Measures......243

C New Standard for Time to Primary PCI Measure......243

D New Reperfusion Therapy Measure......243
Appendix A: ACC/AHA STEMI/NSTEMI Measurement Set Specifications......244
Appendix B: Sample Rating Form and Guide......258
Appendix C: Relationships With Industry—Writing Committee......260
Appendix D: Relationships With Industry—Peer Reviewers......262
References......264

	Preamble

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

 
Medicine is experiencing an unprecedented focus on quantifying and improving health care quality. The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed a multi-faceted strategy to facilitate the process of improving clinical care. The initial phase of this effort was to create clinical practice guidelines that carefully review and synthesize available evidence to better guide patient care. Such guidelines are written in a spirit of suggesting diagnostic or therapeutic interventions for patients in most circumstances. Accordingly, significant judgment by clinicians is required to adapt these guidelines to the care of individual patients, and these guidelines can be generated with varying degrees of confidence based upon available evidence. Occasionally, the evidence supporting a particular structural aspect or process of care is so strong that failure to perform such actions reduces the likelihood that optimal patient outcomes will occur. Creating a mechanism for quantifying these opportunities to improve the outcomes of care is an important and pressing challenge.

In the next phase of its quality improvement efforts, the ACC and the AHA created the ACC/AHA Task Force on Performance Measures in February 2000 to spearhead the development of performance measures that allow the quality of cardiovascular care to be assessed and improved. Three nominees from each organization were charged with the task of assembling teams of clinical and methodological experts, both from within the sponsoring organizations and from other organizations dedicated to the care of patients covered by the performance measurement set. These writing committees were given careful guidance with respect to the necessary attributes of good performance measures and the process of identifying, constructing, and refining these measures so that they can accurately achieve their desired goals (1).

The role of performance measurement writing committees is not to perform a primary evaluation of the medical literature; this is undertaken by ACC/AHA guidelines committees. However, performance measurement writing committees work collaboratively with guidelines committees so that the guideline recommendations are written with a degree of specificity that supports performance measurement and so that new knowledge can be rapidly incorporated into performance measurement. Development of ACC/AHA guidelines includes a detailed review of and ranking of the evidence available for the diagnosis and treatment of specific disease areas. Published guideline recommendations employ the ACC/AHA classification system I, IIa, IIb, and III (Fig. 1).

View larger version (72K): [in this window] [in a new window]   Figure 1 ACC/AHA classification of recommendations for practice guidelines.

ACC/AHA Performance Measurement Sets are to be applied in either the inpatient and/or outpatient setting depending upon the topic. Although inpatient measures have traditionally been captured by retrospective data collection, the increased use of electronic medical records allows for prospective collection in the inpatient and outpatient settings. Prospective data collection is itself a continuous quality improvement process. The performance measures quantify explicit actions performed in carefully specified patients for whom adherence should be advocated in all but the most unusual circumstances. In addition, the measures are constructed with the intent to facilitate both retrospective and prospective data collection using explicit administrative and/or easily documented clinical criteria. Furthermore, the data elements required to construct the performance measures are identified and linked to existing ACC/AHA Clinical Data Standards to encourage the standardization of cardiovascular measurement.

While the focus of the performance measures writing committees is to develop measures for internal quality improvement, it is appreciated that other organizations may use these measures for external reporting of provider performance. Therefore, it is within the scope of the writing committee’s task to comment on the strengths and limitations of externally reporting potential performance measures. Specifically, this was done in the inpatient measurement set, where a "Challenges to Implementation" section was included below the specification, when appropriate (see Appendix A).

All the measures contained in this set have limitations and challenges to implementation that could result in unintended consequences when used for accountability purposes. The implementation of these measures for purposes other than quality improvement (QI) require field testing to address issues related to, but not limited to, sample size, reasonable frequency of use for an intervention, comparability, and audit requirements. The way in which these issues are addressed will be highly dependent on the type of accountability system developed including data collection method, assignment of patients to physicians for measurement purposes, baseline measure setting, incentive system, and public reporting method among others. The ACC/AHA encourages those interested in working on implementation of these measures for purposes beyond QI to work with the ACC/AHA to understand these complex issues in pilot testing projects that can measure the impact of any limitations and provide guidance on possible refinements of the measures that would make them more suitable for additional purposes.

In the process of facilitating the measurement of cardiovascular health care quality, the ACC/AHA Performance Measurement Sets can serve as a vehicle for more rapidly translating the strongest clinical evidence into practice. These documents are intended to provide practitioners with "tools" for measuring the quality of care and for identifying opportunities to improve. Because the target audience and unit of analysis for these measures is the practitioner, they were constructed from the provider’s perspective and were not intended to characterize "good" or "bad" practice but to be part of a system with which to assess and improve health care quality. It is our hope that an application of these performance measures within a system of QI will provide a mechanism through which the quality of medical care can be measured and improved.

Robert O. Bonow, MD, FACC, FAHAChair, ACC/AHA Task Force on Performance Measures

	I. Introduction

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

 
The ACC/AHA ST-Elevation and Non–ST-Elevation Myocardial Infarction (STEMI/NSTEMI) Performance Measures Writing Committee was charged with the development of performance measures concerning the diagnosis and treatment of both ST-elevation myocardial infarction (STEMI) and non–ST-elevation myocardial infarction (NSTEMI) (see the Methodology section for detailed information on how the measures were constructed and selected.)

A. Scope of the Problem.   Both STEMI and NSTEMI afflict an enormous number of people each year. The estimated incidence of myocardial infarction (MI) is 865 000 attacks annually. Twenty percent of men and 30% of women will die within 1 year after having an initial recognized MI. The risk of further cardiac disease complications, such as another heart attack, sudden death, angina pectoris, heart failure and stroke for those who survive an MI is substantial (2).

Over the past 30 years, advances in cardiovascular care have resulted in a dramatic decline in mortality and morbidity associated with STEMI and NSTEMI (3). However, there is strong evidence that the best treatments and strategies for these patients are not always pursued. As a result, the outcomes of STEMI and NSTEMI patients are not as good as they could be with better translation of the best scientific knowledge to the bedside.

B. Writing Committee Structure/Members.   The members of the ACC/AHA STEMI/NSTEMI Performance Measures Writing Committee included senior clinicians, a content expert on STEMI and NSTEMI performance measurement, a methodologist, and a statistician. The Writing Committee also included members of the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), and the American College of Emergency Physicians (ACEP).

C. Independence/Relationships With Industry Disclosure.   The work of the Writing Committee was supported exclusively by the ACC and the AHA. Writing Committee members volunteered their time, and there was no commercial support. Meetings of the Writing Committee were confidential and attended only by committee members and staff. All Writing Committee members with relationships with industry relevant to this topic declared these in writing according to standard ACC and AHA reporting requirements; additionally, members verbally acknowledged these relationships to the Writing Committee. Please see Appendix C for relevant Writing Committee relationships with industry. In addition, Appendix D includes relevant relationships with industry information for all peer reviewers of this document.

D. Review/Endorsement.   During the period August 13, 2004 to September 13, 2004, the ACC/AHA STEMI/NSTEMI Performance Measures document underwent a 30-day public comment period during which time ACC and AHA members, as well as other health professionals, had an opportunity to review and comment on the final draft document in advance of its final approval and publication. Over 40 responses were received.

The official peer and content review of the document was conducted simultaneously with the 30-day public comment period, with two peer reviewers nominated by the ACC and two reviewers nominated by the AHA. Additional comments were sought from clinical content experts and performance measurement experts.

The ACC/AHA Clinical Performance Measures for Adults with ST-Elevation and Non–ST-Elevation Myocardial Infarction was adopted by the respective Boards of the ACC and AHA on October, 2005. These measures will be reviewed for currency annually and will be updated as needed. They will be considered valid until they are updated or rescinded by the ACC/AHA Task Force on Performance Measures.

	II. Methodology

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

 
The development of performance systems involves identification of a set of measures targeted toward a particular patient population, observed over a particular time period. To achieve this goal, the ACC/AHA Task Force on Performance Measures has outlined and published a methodology of sequential tasks that writing committees are required to complete (1). The following sections outline how these steps were applied by this Writing Committee.

A. Definition of STEMI/NSTEMI.   The Writing Committee has incorporated the use of the terms STEMI and NSTEMI throughout this document along with the all-inclusive term acute myocardial infarction (AMI) based on the revision of the 1999 ACC/AHA Guideline for the Management of Patients with Acute Myocardial Infarction (4). This guideline update resulted in the topic of AMI being separated into two guidelines: the ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction (5) and the 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (6). The Writing Committee has used the term AMI when the measure refers to both STEMI and NSTEMI patients, while the term STEMI was used in cases in which the clinical recommendation is specific to STEMI patients only. Measures specific to NSTEMI patients only are not contained in this set but may be considered in future updates.

Specific diagnosis codes, based on ICD-9-CM (Table 1), should be used to screen and select the inpatient target patient population. These codes correspond to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Centers for Medicare and Medicaid services (CMS) AMI cohort selection codes.

C. Literature Review.   As the primary sources for deriving these measures, this Writing Committee reviewed the 1999 ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction (AMI Guideline) (4), the ACC/AHA 2002 Guideline Update for Management of Patients with Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction (UA/NSTEMI guideline) (5), and the 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (STEMI guideline) (6). The Chair of this Writing Committee also participated on the Writing Committee of the latter guideline. As a participant on the guideline committee, the Chair was able to offer insights into measurement issues and provide suggestions for clarity and specificity of guideline recommendations. At the same time, the guideline contributed to the refinement of the measures developed by this Writing Committee.

In addition, existing measure sets, such as those developed by the JCAHO and CMS, were reviewed by the Writing Committee. See the Discussion section for details on our efforts to align our measures with CMS and JCAHO.

D. Definition and Selection of Measures.   Explicit criteria exist for the development of performance measures so that they can accurately reflect the quality of care, including quantification of the numerator and denominators of potential measures and evaluating the interpretability, applicability, and feasibility of the proposed measure. To determine which measures would be considered for inclusion in the performance measurement set, the Writing Committee reviewed and prioritized the class I and class III recommendations as potential quality indicators from the AMI guideline, the UA/NSTEMI guideline, and the STEMI guideline (4–6).

From the analysis of these recommendations, the Writing Committee identified potential measures relevant to the treatment of STEMI and NSTEMI patients. Using the ACC/AHA performance measure rating form and guide (Appendix B), each Writing Committee member rated potential measures on 13 dimensions using a 5-point Likert scale (1 = lowest rating; 5 = highest rating) against the ACC/AHA attributes for good performance measures (Table 2).

In the case of the measure for angiotensin-converting enzyme inhibitor (ACEI), a Class IIa ACC/AHA STEMI guidelines recommendation for angiotensin receptor blockers (ARB) was considered and used as the basis for clarifying the measure constructed by the committee. Although class IIa recommendations are not considered for stand-alone measures, in some cases (such as this one) they provide additional information about valid alternative therapies that are considered by the committee for inclusion in a measure set.

	III. STEMI/NSTEMI performance measures

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

 
A. Inpatient Population and Care Period.   The inpatient target population consists of patients aged 18 years or older with a principal discharge diagnosis of AMI (STEMI and NSTEMI) based on ICD-9-CM (Table 1). A set of inclusion and exclusion criteria specific to each inpatient measure was developed. The general period of assessment is the related inpatient hospitalization. The specific time period of interest for each measure is further defined in the full measure specifications (Appendix A).

B. Brief Summary of the Measurement Set.   Table 3 shows the ACC/AHA STEMI/NSTEMI performance measurement set—those with the highest level of evidence and full-consensus support among the committee members. The measures include aspirin therapy at arrival and discharge, beta-blocker therapy at arrival and discharge, low-density lipoprotein cholesterol (LDL-c) assessment, lipid-lowering therapy at discharge, ACEI, and/or ARB therapy, time-to-fibrinolytic therapy, time-to-percutaneous coronary intervention (PCI), reperfusion therapy, and smoking cessation advice/counseling.

C. Data Collection.   To aid in the collection of hospital data, use of a data collection tool or flow sheet is recommended. The flow sheet may be developed at individual institutions to conform to local workflow issues and data collection practices. Examples of useful data collection tools are available from ACC’s Guideline Applied in Practice (GAP) program Web site (http://www.acc.org/gap/mi/ami_downloadA.htm) and the AHA’s Get With The Guidelines (GWTG) program web site (http://www.americanheart.org/presenter.jhtml?identifier=3003994). The tools can be modified for implementation at your institution in order to be used in practice.

To further the use of standardized terminology and data definitions in the field of cardiology, those collecting data on patients with STEMI or NSTEMI are referred to the ACC Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients with Acute Coronary Syndromes (7).

	IV. Discussion

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

 
The ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non–ST-Elevation MI addresses many of the same processes of care as earlier measurement sets published by other organizations. These measures were developed by employing the ACC/AHA methodology for developing performance measure sets (3). The Writing Committee has been cognizant of the previous efforts of other groups and sought to enhance and clarify measures in ways that reflect the advancement of the underlying science, the complexity of care, and the challenges of accurate and complete data collection. As such, the Writing Committee has made every attempt to align these measures with those promulgated by CMS and JCAHO.

This Writing Committee felt it was important to add exclusion criteria to the measures to recognize that there are justifiable medical and patient reasons for not meeting the performance measures. These reasons should be included in the "reasons documented by physician, nurse practitioner, or other health care provider for not..." Documentation of such factors should be encouraged and will provide valuable data for future research and conducting in-depth QI for situations where there seem to be outliers with respect to the number of patients with medical or patient-centered exclusions for the performance measures.

Challenges to implementation of measures are discussed, where applicable. In general, inadequate documentation is the initial challenge of any measurement effort. The fact that these challenges are discussed is not intended as an argument against measurement. Rather, they should be considered as cautionary notes that draw attention to areas where additional focus on research and improvement of the measures should be considered.

Four areas in this measurement set warrant further discussion: the addition of ARBs to the ACEI for left ventricular systolic dysfunction (LVSD) measure (#7), the use of "median" versus "mean" in the time-to-fibrinolytic measure (#8), the new standard for the time-to-PCI measure (#9), and the new reperfusion therapy (#10) measure.

A. Addition of ARBs to ACEI Measure.   The measurement set includes ARBs along with ACEI prescription on discharge. Although Class IIa recommendations are not considered for stand-alone measures, in this case, the additional information provided about valid alternative therapies allowed it to be considered for inclusion in the measure. This change is made with recognition that although the guidelines still recommend ACEI as first-line therapy, physicians should be given credit for prescribing or continuing ARB therapy. The support for the use of ARBs has evolved significantly in response to published clinical trials that have shown ARBs as an effective alternative therapy and is recommended in the 2004 ACC/AHA STEMI guidelines (6) as a reasonable alternative therapy.

B. Median—Time-to-Fibrinolytic Therapy and Time-to-Primary PCI Measures.   Median better represents the typical time achieved than does mean. The mean time can be unduly skewed by outlier times, even as there are upper limits on the time. Thus, the committee favored reporting the median time. This is a contrast with the corresponding CMS/JCAHO measure, which reports the values in mean time. The CMS/JCAHO equivalent measures will report the median for discharges effective January 1, 2006. The information was released to the community in late August 2005.

C. New Standard for Time-to-Primary PCI Measure.   This measurement set establishes the time-to-PCI standard at 90 min, which is different than the 120-min standard used in the current CMS and JCAHO measures. This change reflects the new recommendation from the 2004 ACC/AHA STEMI guidelines that, "delay from patient contact with the health care system (typically, arrival at the emergency department or contact with paramedics) to balloon inflation should be less than 90 min" (6).

D. New Reperfusion Therapy Measure.   The new reperfusion therapy measure is meant to capture the percentage of patients eligible for reperfusion (either fibrinolytic therapy or PCI) who are reperfused. This measure is meant to assist facilities in assessing the appropriateness of their use of reperfusion therapy and detecting underutilization of reperfusion.

Although the Writing Committee considered a number of additional potential measures that focus on equally important aspects of care, either the evidence base or more significant challenges to measurement of these components of care across all patients undermined the benefits that might be gained. Of note, the committee discussed at length the possibility of including a clopidogrel measure and a measure for ACEI in patients with left ventricular ejection fraction (LVEF) greater than 0.40, but it felt that the evidence-base did not yet support their inclusion as a performance measure. The Writing Committee will monitor changes in the evidence in new clinical trials and will determine whether additional measures should be added in the future.

The ACC/AHA STEMI/NSTEMI performance measurement set should contribute to the evolution of reporting systems that allow physicians to improve care for a critical patient population. QI is a continuous process, and this document reflects the lessons the practicing community has learned to date in using existing measures and knowledge gained about how they might be improved. The clinical care team should collect data and review adherence to these measures on a routine basis, look for changes, and adjust practice patterns as necessary to improve performance.

Staff.   American College of Cardiology Foundation

Christine W. McEntee, Chief Executive Officer

Joseph M. Allen, MA, Director, Clinical Decision Support

Tilithia McBride, Senior Specialist, Clinical Performance Measurement

Susan L. Morrisson, Associate Specialist, Clinical Performance Measurement

American Heart Association

M. Cass Wheeler, Chief Executive Officer

Gayle R. Whitman, PhD, RN, FAAN, Vice President, Office of Science Operations

Fernando Costa, MD, FAHA, Staff Scientist

	APPENDIX A. ACC/AHA STEMI/NSTEMI Measurement Set Specifications

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

	APPENDIX B. Sample Rating Form and Rating Form Guide

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

	APPENDIX C. Relationships With Industry—ACC/AHA Writing Committee to Develop Performance Measures on ST-Elevation MI/Non–ST-Elevation MI

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

	APPENDIX D. Relationships With Industry–External Peer Reviewers for the ACC/AHA Clinical Performance Measures for Adults With ST-Elevation MI/Non–ST-Elevation MI*

Top Table of Contents Preamble I. Introduction II. Methodology III. STEMI/NSTEMI performance... IV. Discussion APPENDIX A. ACC/AHA STEMI/NSTEMI... APPENDIX B. Sample Rating... APPENDIX C. Relationships With... APPENDIX D. Relationships With... References

	Footnotes

 
This document was approved by the American College of Cardiology Board of Trustees in October 2005 and the American Heart Association Science Advisory and Coordinating Committee in October 2005.

When citing this document, the American College of Cardiology would appreciate the following citation format: Krumholz HM, Anderson JL, Brooks NH, Fesmire FM, Lambrew CT, Landrum MB, Weaver WD, Whyte J. ACC/AHA Clinical Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction: a report of the ACC/AHA Task Force on Performance Measures (ST-Elevation and Non–ST-Elevation Myocardial Infarction Performance Measures Writing Committee). J Am Coll Cardiol 2006;47:236–65.

Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (www.americanheart.org). Single copies of this document as published in the January 3, 2006 issue of the Journal of the American College of Cardiology and the January 3, 2006 issue of Circulation are available for $10.00 each by calling 1-800-253-4636 or writing the American College of Cardiology Foundation, Resource Center, at 9111 Old Georgetown Road, Bethesda, Maryland 20814-1699. To purchase bulk reprints specify reprint number—71-0350 for the published document: Up to 999 copies, call 1-800-611-6083 (U.S. only) or fax 413-665-2671; 1,000 or more copies, call 214-706-1466, fax 214-691-6342, or E-mail: mailto:pubauth{at}heart.org.

Permissions: Copies, modification, alteration, enhancement and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please direct requests to mailto:copyright_permissions{at}acc.org.

^_* Immediate past Task Force Chair

Former Task Force Member

	References

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