Coronary Artery Disease Performance Measures and Statin Use in Patients With Recent Percutaneous Coronary Intervention or Recent Coronary Artery Bypass Grafting (from the NCDR PINNACLE Registry)

Coronary Artery Disease Performance Measures and Statin Use in Patients With Recent Percutaneous Coronary Intervention or Recent Coronary Artery Bypass Grafting (from the NCDR PINNACLE Registry)

Coronary Artery Disease Performance Measures and Statin Use in Patients With Recent Percutaneous Coronary Intervention or Recent Coronary Artery Bypas...

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Coronary Artery Disease Performance Measures and Statin Use in Patients With Recent Percutaneous Coronary Intervention or Recent Coronary Artery Bypass Grafting (from the NCDR PINNACLE Registry) Salman J. Bandeali, MDa,b,*, Kensey Gosch, MSc, Mahboob Alam, MDa,d, Waleed T. Kayani, MDa,d, Hani Jneid, MDd,e, Fran Fiocchi, MPHf, James M. Wilson, MDb, Paul S. Chan, MDg, Anita Deswal, MD, PhDd,e, Thomas M. Maddox, MDh, and Salim S. Virani, MD, PhDd,e,i,j,k The association between coronary revascularization strategy (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) and compliance with coronary artery disease (CAD) performance measures is not well studied. Our analysis studied patients enrolled in the Practice Innovation and Clinical Excellence registry, who underwent coronary revascularization using PCI or CABG in the 12 months before their most recent outpatient visit in 2011. We compared the attainment of CAD performance measures and statin use in eligible patients with PCI and CABG using hierarchical logistic regression models. Our study cohort consisted of 112,969 patients (80,753 with PCI and 32,216 with CABG). After adjustment for site and patient characteristics, performance measure compliance for tobacco use query (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.76 to 0.86), antiplatelet therapy (OR 0.9; 95% CI 0.86 to 0.94) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (OR 0.89; 95% CI 0.84 to 0.94) was lower in CABG compared with patients with PCI. Patients who underwent recent CABG had higher rates of b-blocker (OR 1.25; 95% CI 1.16 to 1.33) and statin treatment (OR 1.37; 95% CI 1.31 to 1.43) compared with patients with PCI. Of the 79 practice sites, 15 (19%) had ‡75% of their patients with CAD (CABG or PCI) meeting 75% to 100% of all eligible CAD performance measures. In conclusion, gaps persist in compliance with specific CAD performance measures in patients with recent PCI or CABG, and 1 in 5 practices had ‡75% compliance of eligible CAD performance measures in the most of their patients. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015;115:1013e1018) Revascularization either using percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) represents an important event in patients with coronary artery disease (CAD). Both PCI and CABG and the subsequent outpatient care that ensues provide opportunity to improve control of cardiovascular risk factors in this secondary prevention known to have a high risk of recurrent cardiovascular

a Department of Medicine, dSection of Cardiology, and jSection of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; bSection of Cardiology, Department of Medicine, Texas Heart Institute, CHI/ Baylor St. Luke’s Medical Center, Houston, Texas; Departments of cCardiovascular Outcomes Research and g Medicine, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri; eSection of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; fAmerican College of Cardiology Foundation; hVA Eastern Colorado Health Care System/University of Colorado School of Medicine, Denver, Colorado; iHealth Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas; and kCenter for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas. Manuscript received September 29, 2014; revised manuscript received and accepted January 20, 2015. See page 1018 for disclosure information. *Corresponding author: Tel: (713) 533-2509; fax: (713) 748-7359. E-mail address: [email protected] (S.J. Bandeali).

0002-9149/15/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2015.01.532

events.1 The exact impact of mode of revascularization (percutaneous coronary revascularization [PCI] or CABG) on attainment of the American Heart Association/American College of Cardiology Foundation (AHA/ACCF) CAD performance measures is not well known.2 There are no studies directly comparing compliance with AHA/ACCF CAD performance measures in a national cohort of patients who have undergone recent PCI or CABG. A greater number of patients who underwent PCI compared with those who underwent CABG present with acute coronary syndrome.3e5 Additionally, the differences in practice patterns and the frequency of outpatient follow-up visits in the 2 groups could also lead to differences in compliance rates with specific CAD performance measures. We aimed to compare compliance with CAD performance measures in patients enrolled in the Practice Innovation and Clinical Excellence (PINNACLE) registry who underwent recent revascularization with either PCI or CABG. Statin use is currently not considered a performance measure for CAD; however, given the recent emphasis on the use of statin therapy as first-line treatment in patients with CAD, we also assessed whether the use of evidence-based statin therapy varies between these 2 groups.6 Methods Among the National Cardiovascular Data Registry (NCDR), the PINNACLE program is the largest outpatient www.ajconline.org

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Figure 1. Details of study cohort development.

registry of cardiovascular disease patients.7 The PINNACLE registry represents the US first national prospective, outpatient registry for quality improvement in care and outcomes of cardiac patients.7e9 For the current analyses, we identified patients with CAD enrolled in the PINNACLE registry with clinic visits from January 1, 2011, to December 31, 2011. If a patient had multiple clinic visits during the study interval, the most recent clinic visit was used as the index visit. After identification of the index visit, we identified patients who had revascularization performed within the last 12 months from the index visit. Modes of revascularization included CABG or PCI (bare metal stent use, drug-eluting stent use, or nonstent PCI). Patients aged 18 years (n ¼ 1,981) and patients who had both PCI and CABG performed during the study period (n ¼ 13,060) were excluded from the analyses. The resulting cohort (n ¼ 112,969) was then divided into those who underwent recent CABG (n ¼ 32,216) or recent PCI (n ¼ 80,753) (Figure 1). The outcome of interest for our study was the proportion of patients in the CABG or the PCI group meeting each of the CAD performance measures. We compared the following performance measures between the 2 groups in accordance with the 2005 AHA/ACCF performance measures in patients with CAD2: (1) blood pressure control (percentage of patients with CAD who had a blood pressure of <140/90 mm Hg or who had a blood pressure of 140/90 mm Hg and were prescribed 2 antihypertensive medications during the most recent office visit), (2) lipid control (percentage of patients with CAD with low-density lipoprotein cholesterol [LDL-C] levels <100 mg/ dl or who had an LDL-C result 100 mg/dl with a documented plan of care to achieve LDL-C <100 mg/dl, including, at a minimum, the prescription of a statin), (3) symptom and activity assessment (percentage of patients with CAD for whom there were documented results of an evaluation of the level of activity and an evaluation of presence or absence of angina symptoms/ angina equivalents in the medical record), (4) tobacco use: screening and intervention (percentage of patients with CAD

who were screened for tobacco use and received tobacco cessation counseling if identified as tobacco users), (5) antiplatelet therapy (percentage of patients with CAD who were prescribed aspirin or clopidogrel), (6) b-blocker therapy use (percentage of patients with CAD with previous myocardial infarction or a current or previous left ventricular ejection fraction (LVEF) 40%, who were prescribed b-blocker therapy), and (7) angiotensin-converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB) use (percentage of patients with CAD with diabetes or a current or previous LVEF 40% who were prescribed ACE-I or ARB therapy). In addition, we also compared the proportion of PCI or CABG patients receiving statin therapy at the index visit. Baseline demographic variables and co-morbidities were compared between the 2 groups (CABG vs PCI) using chisquare statistic for categorical variables and t test for continuous variables. These included gender, health insurance status (private [fee for service or health maintenance organization], public [Medicare, Medicaid, Veterans Affairs Administration], none), history of diabetes mellitus, hypertension, dyslipidemia, previous stroke or transient ischemic attack, peripheral artery disease (PAD), unstable angina, heart failure, body mass index, LVEF, history of myocardial infarction, history of tobacco use (never, current, quit in past 12 months, quit >12 months ago), total cholesterol levels, high-density lipoprotein cholesterol levels, LDL-C levels, and triglycerides. We subsequently examined whether there were differences in compliance with eligible performance measures by mode of revascularization strategy (PCI or CABG) using hierarchical logistic regression models. These models included a random intercept for the office practice and a within-practice estimate of treatment effect to account for differences in volumes and enrollment duration among participating practices. To accomplish this, we first evaluated the proportion of eligible patients in the PCI or CABG groups meeting CAD performance measures. Subsequently, we adjusted for patient and clinical characteristics (in addition to practice effects) to examine the influence of patient factors on observed differences in performance. The following patient-level covariates were used in the adjusted analyses: age, gender, diabetes, dyslipidemia, hypertension, PAD, previous stroke, unstable angina, heart failure, history of myocardial infarction, tobacco use, LVEF, body mass index, atrial fibrillation, systolic blood pressure, diastolic blood pressure, heart rate, weight, cigarette use, and insurance status. Missing covariates were imputed using sequential regression imputation.10 Odds ratios and 95% confidence intervals are reported, and statistical significance was denoted by 2-sided p values <0.05. Additionally, we evaluated the proportion of patients who underwent recent revascularization (either recent CABG or PCI) at each practice site meeting most (75% to 100%) of all eligible CAD performance measures in sites with >20 patients with recent PCI or CABG. Analyses were performed using SAS, version 9.3 for Windows x64 (SAS Institute, Inc., Cary, North Carolina) and R version 2.11.1.11 Results Our study population included 112,969 patients with CAD from the PINNACLE registry, of which 32,216 had undergone recent CABG and 80,573 had recent PCI. The 2

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Table 1 Baseline characteristics of patients who underwent recent CABG or PCI Variable

Age (years) mean  standard deviation Men Caucasian ethnicity Insurance None Private Public Diabetes mellitus *Dyslipidemia † Hypertension Peripheral artery disease Prior stroke/CVA Unstable angina pectoris Heart failure Prior myocardial infarction Tobacco Use Never Current Quit within past 11 months Quit more than 11 months ago LVEF, mean  standard deviation LVEF 50% 40-49% 26-39% 25% Total cholesterol, mean  standard deviation (mg/dL) High density lipoprotein, mean  standard deviation (mg/dL) Low density lipoprotein cholesterol, mean  standard deviation(mg/dL) Triglycerides, mean  standard deviation (mg/dl)

Group

p-Value

CABG [n ¼ 32216]

PCI [n ¼ 80753]

70.7  11.4 23441 (72.9%) 16887 (94.5%)

64.4  14.4 44841 (55.6%) 31138 (86.9%)

1291 15914 11838 11764 26919 27798 20387 11410 988 16919 11260

11591 43854 21758 22025 56893 65825 56627 41666 2477 52203 28869

(4.4%) (54.8%) (40.8%) (36.5%) (83.6%) (86.3%) (63.3%) (35.4%) (3.1%) (52.5%) (35.0%)

(15.0%) (56.8%) (28.2%) (27.3%) (70.5%) (81.5%) (70.1%) (51.6%) (3.1%) (64.6%) (35.7%)

7341 (31.3%) 4400 (18.8%) 1204 (5.1%) 10494 (44.8%) 53.4  13.7

18507 (25.7%) 10272 (14.3%) 1725 (2.4%) 41415 (57.6%) 55.9  12.7

2444 (57.9%) 998 (23.7%) 442 (10.5%) 335 (7.9%) 154.7  40.5 45.2  14.5 84.6  36.9 137.5  105.2

6457 (60.0%) 2962 (27.5%) 855 (7.9%) 493 (4.6%) 165.4  42.5 49.0  16.0 91.2  38.6 137.7  110.7

< < < <

0.001 0.001 0.001 0.001

< < < < <

0.001 0.001 0.001 0.001 0.001 0.996 < 0.001 0.011 < 0.001

< 0.001 < 0.001

< 0.001 < 0.001 < 0.001 0.859

CABG ¼ coronary artery bypass grafting; CVA ¼ cerebrovascular accident; LVEF ¼ left ventricular ejection fraction; PCI ¼ percutaneous coronary intervention. * Dyslipidemia defined as by the National Cholesterol Education Program criteria and includes documentation of the following: 1. Total cholesterol greater than 200 mg/dL (5.18 mmol/l); or 2. Low-density lipoprotein cholesterol (LDL-C) greater than or equal to 130 mg/dL (3.37 mmol/l); or 3. High-density lipoprotein (HDL-C) less than 40 mg/dL (1.04 mmol/l). For patients with known coronary artery disease, treatment is initiated if LDL-C is greater than 100 mg/dL (2.59 mmol/l), and this would qualify as hypercholesterolemia. † Hypertension defined by any of the following: History of hypertension diagnosed and treated with medication, diet and/or exercise. 2. Prior documentation of blood pressure greater than 140 mm Hg systolic and/or 90 mm Hg diastolic for patients without diabetes or chronic kidney disease, or prior documentation of blood pressure greater than 130 mm Hg systolic and/or 80 mm Hg diastolic on at least two occasions for patients with diabetes or chronic kidney disease. 3. Currently on pharmacologic therapy for treatment of hypertension.

patient populations were significantly different from each other in terms of baseline characteristics (Table 1). CABG patients were older, had a higher proportion of Caucasians and men, and had higher prevalence of diabetes, dyslipidemia, hypertension, current smoking, and LV systolic dysfunction (LVEF <40%) compared with patients with PCI. Patients in the PCI group had a higher prevalence of PAD and previous stroke or transient ischemic attack. Patients with recent CABG had lower levels of total cholesterol, LDL-C, and high-density lipoprotein cholesterol compared with the patients in the recent PCI group. Table 2 describes the proportion of patients in each group meeting individual CAD performance measures and comparison between the 2 groups after adjusting for patient and site characteristics. Overall, compliance was highest for performance measure of blood pressure control in both

groups (97.3% for CABG and 98.3% for patients with PCI), whereas it was lowest for lipid control (23.8% each for the CABG and the PCI groups) and symptoms/activity assessment (28.7% and 19.9% for the CABG and the PCI groups, respectively). After adjusting for site and patient characteristics (Table 2), patients with recent CABG were less likely to meet the performance measures for tobacco use query (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.76 to 0.86), antiplatelet therapy (OR 0.90, 95% CI 0.86 to 0.94), and ACE-I/ARB therapy (OR 0.89, 95% CI 0.84 to 0.94) compared with patients with PCI. CABG patients were more likely to meet the performance measure for b-blocker therapy (OR 1.25, 95% CI 1.16 to 1.33) and to be on statin therapy (OR 1.37, 95% CI 1.31 to 1.43) compared with patients with PCI. Compliance with CAD performance measures of blood pressure control, lipid control, symptom and activity

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Table 2 Proportion of patients meeting each CAD performance measures among patients with recent CABG or PCI CAD performance measure

Blood pressure control Lipid control Symptom and activity assessment Tobacco use query Tobacco cessation intervention Antiplatelet therapy Beta-blocker therapy ACE-I/ARB therapy Statin use

CABG group[ n¼ 32,216] Number meting a performance measure/ number eligible (% eligible meeting a measure)

PCI group [n¼ 80,753] Number meeting a performance measure/ number eligible (% eligible meeting a measure)

Likelihood of compliance with performance measure in CABG group compared to PCI group (referent) OR (95%CI) [Unadjusted]

Likelihood of compliance with performance measure in CABG group compared to PCI group (referent) OR (95%CI) *[Adjusted for site and patient characteristics]

31344/32216 (97.3%) 7661/32216 (23.8%) 9245/32216 (28.7%)

79385/80753 (98.3%) 19255/80753 (23.8%) 16032/80753 (19.9%)

0.62 (0.57, 0.68) 1.00 (0.97, 1.03) 1.62 (1.58, 1.67)

0.97 (0.85, 1.10) 1.00 (0.96, 1.04) 0.98 (0.92, 1.05)

23439/32216 (72.8%) 381/1142 (33.4%)

71919/80753 (89.1%) 1121/3476 (32.3%)

0.33 (0.32, 0.34) 0.90 (0.75, 1.08)

0.80 (0.76, 0.86) 0.90 (0.74, 1.09)

25651/32133 (79.8%) 8797/11041 (79.7%) 8770/13093 (67.0%) 25187/31875 (79.0)

51134/80615 (63.4%) 20333/28273 (71.9%) 15638/24128 (64.8%) 48625/79419 (61.2)

2.28 1.53 1.10 2.39

0.90 1.25 0.89 1.37

(2.21, (1.45, (1.05, (2.31,

2.35) 1.61) 1.15) 2.46)

(0.86, (1.16, (0.84, (1.31,

0.94) 1.33) 0.94) 1.43)

ACE-I ¼ angiotensin converting enzyme inhibitor; ARB ¼ angiotensin receptor blocker; BP ¼ blood pressure; CABG ¼ coronary artery bypass grafting; CAD ¼ coronary artery disease; CI ¼ confidence interval; HTN ¼ hypertension; LDL-C ¼ low density lipoprotein cholesterol; LVEF ¼ left ventricular ejection fraction; MI ¼ myocardial infarction; OR ¼ Odds ratio; PCI ¼ percutaneous coronary intervention. * Adjusted for age, sex, diabetes, dyslipidemfia, hypertension, peripheral arterial; disease, prior stroke, unstable angina, stable angina, heart failure, history of myocardial infarction, tobacco use, left ventricle ejection fraction, body mass index, atrial fibrillation, systolic blood pressure, diastolic blood pressure, heart rate, weight, cigarette use, insurance status. These analyses also account for differences in volumes and enrollment duration among participating practices.

assessment, and smoking cessation intervention were not significantly different between the 2 groups after adjustment. We also performed exploratory analyses comparing compliance with CAD performance measures among patients who had both PCI and CABG during the study interval with patients who underwent either CABG or PCI. Compliance with CAD performance measures was either greater (for some measures) or similar in patients who underwent both PCI and CABG compared with those who had revascularization either through PCI or CABG (Supplementary Figure 1). The proportion of patients with CAD (CABG or PCI) meeting 75% to 100% of all eligible CAD performance measures at each practice site is described in Figure 2. The proportion varied from 0% of the patients to 100.0% (median ¼ 26%, interquartile range 5.16% to 70.95%). Therefore, half of the practice sites had only 1/4 of their patients meeting 75% to 100% of the eligible CAD performance measures. Of the 79 sites, only 15 (19%) had 75% of their patients meeting 75% to 100% of all eligible CAD performance measures. Restricting analyses to 69 practices with >20 patients with CABG or PCI (Figure 2), only 9 of 69 (13%) practices had has 75% of their patients with CABG or PCI meeting 75% to 100% of all eligible CAD performance measures (Figure 2). Discussion In this analysis from the PINNACLE outpatient registry, we found specifics gaps in CAD performance measures in patients who had undergone CABG or PCI within the past 12 months. After adjustment for site and patient characteristics, patients who had undergone recent CABG were less likely to meet the performance measure for tobacco use query, antiplatelet therapy, and ACE-I/ARB therapy

compared with patients with PCI. In contrast, patients who had undergone recent CABG were more likely to meet the performance measure for b-blocker therapy and to be on statin compared with patients with PCI. More importantly, site-specific analyses showed that only 19% of the practices had >3/4 of their patients with CABG or PCI meeting 75% to 100% all eligible CAD performance measures. Efforts to improve the outcomes of patients with CAD after revascularization have resulted in the development of specific performance measures by the AHA/ACCF.12 Despite relative improvement over the years, there remains room for improvement. A study of 143,999 patients presenting with acute coronary syndrome showed a paradoxically lower compliance of lipid-lowering therapy, ACE-I therapy, and smoking cessation counseling in those with previous vascular disease.13 Hiratzka et al14 studied AHA’s Get With the Guidelines database and reported that compliance with the inpatient use of aspirin, b-blockers, ACE-I therapy, antihyperlipidemic agents, and smoking cessation advice was greater among patients who underwent revascularization with PCI compared with CABG. Our study extends the results of these inpatient studies by evaluating compliance with CAD performance measures in the outpatient setting. Our results indicate that compliance with some performance measures like tobacco use query, ACE-I/ARB therapy, and antiplatelet therapy was lower among patients who underwent recent CABG compared with recent PCI. In contrast, statin use and b-blocker therapy use were higher among patients with CABG compared with patients with PCI. Some of our study results are in contrast to those reported by Hiratzska et al14 in 2007. Hiratzska et al reported that patients who had CABG were less likely to receive most secondary prevention measures including pharmacotherapy with aspirin, ACE-I/ARB, and lipid-lowering drug therapy

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Figure 2. (A) Percentage of patients with CABG or PCI meeting 75% to 100% of the eligible CAD performance measures at participating practices. (B) Percentage of patients with CABG or PCI meeting 75% to 100% of the eligible CAD performance measures at participating sites (after restricting analyses to practices with >20 patients with CABG or PCI).

compared with patients with PCI in the in-hospital setting. On the contrary, our study shows mixed results when comparing patients with CABG and PCI. Compliance with some CAD performance measures (b-blocker and statin use) was higher in the CABG group, whereas compliance with others (e.g., tobacco use query, ACE-I/ARB therapy and antiplatelet therapy) was lower in the CABG group compared with the PCI group. The improvement in some of these evidence-based medical therapies for CAD in patients who underwent CABG might be explained by the involvement of these practices in a quality improvement registry like PINNACLE with routine audit and feedback of their performance on CAD performance measures. The Alabama coronary artery bypass project showed an improvement in aspirin, b-blocker, and lipid-lowering drug use at discharge for a 6-year period in patients who underwent CABG.15

Another institutional study at the University of Kentucky evaluated compliance with 2001 AHA/ACCF performance measure for CAD in patients with CABG. Institution of this rigorous quality improvement project resulted in an improvement in all CAD performance measures compared with the control group.14,16 One of the most important findings of our study is that only 19% of the practice sites had 75% of their recently revascularized patients showing 75% to 100% compliance with all eligible CAD performance measures. The percentage was even lower in practices with >20 patients with CABG or PCI (13%). The observation of low overall compliance at each practice site with global CAD performance measures in this secondary prevention population is concerning given the high risk of recurrent coronary events seen in patients with established atherosclerosis. These results indicate that

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although compliance with each performance measure when analyzed separately might be high, compliance with all eligible performance measures in individual patients with CAD with recent revascularization was low. These results highlight a need for future quality improvement initiatives aimed at improving global compliance with all eligible CAD performance measures in patients who have undergone coronary revascularization, be it CABG or PCI. Our study has limitations. The PINNACLE registry relies on voluntary participation of practices, and hence, the characteristics of patients in the registry and CAD performance measures compliance might differ from that of the general outpatient population. The number of patients for the measure of tobacco cessation intervention was small to derive valid conclusions for this performance measure. The results could have been influenced by variations in documentation practices of providers. These included under-reporting of over-the-counter medications like aspirin use or a contraindication to the use of a medication. Some patients with an indication for therapy may decrease it for personal preference or side effects that may not have been captured accurately. In addition, some health care providers may not document symptoms and activity assessment or tobacco use at each patient visit leading to under ascertainment of these measures in our study. The strength of our study includes comparison of a large population of patients with CABG or PCI from an NCDR. The results of our study highlight a need for future quality improvement initiatives aimed at improving global compliance with all CAD performance measures in patients who have undergone recent coronary revascularization. Disclosures Drs. Maddox and Virani are supported by the Department of Veterans Affairs Health Services Research and Development Service (HSR&D) Career Development Award. Dr. Virani is also supported by the American Heart Association and the American Diabetes Association. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Supplementary Data Supplementary data related with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.amjcard. 2015.01.532. 1. Murphy SA, Antman EM, Wiviott SD, Weerakkody G, Morocutti G, Huber K, Lopez-Sendon J, McCabe CH, Braunwald E. Reduction in recurrent cardiovascular events with prasugrel compared with clopidogrel in patients with acute coronary syndromes from the TRITONTIMI 38 trial. Eur Heart J 2008;29:2473e2479. 2. American College of Cardiology Foundation/American Heart Association/American Medical Association—Physician Consortium for Performance Improvement. Clinical Performance Measures. Chronic Stable Coronary Artery Disease. Chicago: American Medical Association, 2005. 3. Kalla K, Christ G, Karnik R, Malzer R, Norman G, Prachar H, Schreiber W, Unger G, Glogar HD, Kaff A, Laggner AN, Maurer G,

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