A collaborative approach to develop indicators for quality of care for ST segment Elevation Myocardial Infarction in networks without coronary intervention: A position paper

Abstract

BACKGROUND:

Data about performance measures (PM) in patients with ST segment Elevation Myocardial Infarction (STEMI) in low- and middle-income countries is really scarce. One of the reasons is the lack of appropriate measures for these scenarios where coronary intervention is not the standard treatment.

OBJECTIVE:

This study aimed to develop a set of PM and quality markers for patients with STEMI in these countries.

METHODS:

Two investigators systematically reviewed existing guidelines and scientific literature to identify potential PM by referring to documents searched through PubMed from 2010 through 2019, using terms “Myocardial Infarction”, “STEMI”, “quality indicator”, and “performance measure”. A modified Delphi technique, involving multidisciplinary panel interview, was used. A 15-member multidisciplinary expert panel individually rated each potential indicator on a scale of 1 (lowest) to 5 (highest) during three rounds. All indicators that received a median score ≥4.5, in final round without significant disagreement were included as PM.

RESULTS:

Through the consensus-building process, 84 potential indicators were found, of which 10 were proposed as performance measures and 2 as quality metrics, as follows: Pre-Hospital Electrocardiogram; Patients with reperfusion therapy; Pre-hospital Reperfusion; Ischemic time less than 120 minutes; System delay time less than 90 minutes; In-hospital Mortality; Complete in-hospital Treatment; Complete in-hospital Treatment in patients with Heart Failure; 30 day-Re-admissions; 30 day-mortality; Patients with in-hospital stress test performed; and, Patients included in rehabilitation programs.

CONCLUSION:

This document provides the official set of PM of attention in ST segment Elevation Myocardial Infarction of the Cuban Society of Cardiology and Cuban National Group of Cardiology.

Keywords

Performance measures quality markers STEMI Cuba low- and middle-income countries

1. Introduction

Cardiovascular diseases, including conditions that affect the heart or blood vessels such as coronary artery disease, acute myocardial infarction (AMI), and unstable angina, are considered to be a true epidemic in the 21st century, representing just over 15% of all deaths in developed countries [1]. Approximately 17 million people in the United States alone are affected by these diseases, with 700,000 new patients added annually [2].

While there has been a decrease in mortality over the past few years, adherence to therapeutic guidelines that are periodically updated by various prestigious associations is necessary to maintain this trend [3–6]. However, discrepancies have been found between the results obtained in clinical trials and the behavior of healthcare providers in the “real world” [6].

In order to monitor and evaluate the quality of healthcare provided, certain parameters have been previously identified. Research has facilitated comparisons between institutions and determined adherence to evidence-based protocols [7–10]. Longitudinal follow-up of these parameters has allowed the creation of strategies to increase the quality of care and improve the patient’s prognosis [11–13].

Research based on quality of care has been designed to monitor changes in healthcare and offer a firm basis for advising which strategies would be beneficial in order to increase the quality of care [14]. Moreover, such research provides stimuli to enhance changes in strategies currently being used, significantly reducing differences [15].

In 2008, the American College of Cardiology and the American Heart Association (ACC/AHA) published two scholarly articles setting forth the methodology for the selection and creation of performance measures to quantify the quality of cardiovascular care and their classification [16,17]. Since then, several associations have provided their lists of quality indicators and performance measures [5,18–20].

Although efforts have been made in this country to quantitatively determine the quality of care for patients with acute coronary syndrome [21,22], they are not identified as indicators of quality of care and have not followed the suggested methodology from ACC/AHA.

Institutions that require professional performance measures (PM) for patients with AMI have shown a greater degree of adherence to therapeutic guidelines. The quality of care that patients receive is significantly different in institutions that follow these parameters compared to those that do not. This leads to lower complication and mortality rates and ultimately results in more favorable prognoses and higher quality of life [18].

Adherence to protocols has been shown to be related to a better prognosis. This difference in prognosis decreases in centers where the indicators of quality of care are determined through regional registries with real-time analysis of data, allowing inference of behavioral patterns of certain variables [15].

Accordingly, the present study aims to propose a set of performance measures for attention in patients with ST Elevation Myocardial Infarction (STEMI) based on a comprehensive review and panel discussion. We expect the proposed measures to be used in cardiology training hospitals for creating and refining systems for attention of these patients in the near future.

2. Material and methods

2.1. Followed methodology

The authors followed the methodology used by the American College of Cardiology and the American Heart Association to create performance measures and quantify aspects of care that directly reflect the quality of cardiovascular care [23].

2.2. Selection of potential performance measures and domains

Two investigators systematically reviewed existing guidelines and scientific literature from 2010 through 2019 to identify potential performance measures. They searched PubMed MEDLINE using a strategy that involved two search terms. The initial search term included “quality indicator”, “performance measures”, and “quality measures”. The final search term included “in STEMI” and “in myocardial infarction”. The two search terms were combined to form a search query with up to six terms, such as “quality indicators in STEMI” (997 retrieved results) and “performance measures in myocardial infarction” (3947 retrieved results).

Due to the large number of reports initially found, only manuscripts classified as Practice Guidelines or Societies Statements documents were fully screened for inclusion. The researchers also screened the references of these documents to find any relevant articles that may have been missed in the initial search. In addition, they accessed the websites of several cardiac associations to find specific documents on performance measures or quality indicators for STEMI that were not found in the initial search.

Then, researchers also accessed websites of several cardiac associations with the goal to find specific documents on performance measures or quality indicators on attention of STEMI, that couldn’t be found. Several documents were obtained:

2016 National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes [3].

2016 Quality indicators for acute myocardial infarction: A position paper of the Acute Cardiovascular Care Association [18].

2017 AHA/ACC Clinical Performance and Quality Measures for Adults with ST- Elevation and Non–ST-Elevation Myocardial Infarction [19].

2017 European Society of Cardiology guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation [5].

2017 Cardiological Society of India: Position statement for the management of ST segment elevation myocardial infarction in India [24].

2017 China Society of Cardiology of Chinese Medical Association Editorial Board of Chinese Journal of Cardiology. Guideline for diagnosis and treatment of patients with ST-elevation myocardial infarction [25].

2018 Task Force on Primary Percutaneous Coronary Intervention (PCI) of the Japanese Cardiovascular Interventional Therapeutics (CVIT) expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) [26].

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion [27].

2020 Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries [28].

2020 Management of patients with acute ST-segment elevation myocardial infarction in Russian hospitals adheres to international guidelines [29].

2020 Update of 2014 NICE Acute coronary syndromes in adults. Quality standard [4].

Thereafter, the results of this comprehensive review were used to identify the best practices for STEMI patients and to develop potential PMs based on Donabedian’s structure-process-outcome model. The PMs were designed to be gathered by general cardiologists and applied to patients with AMI. Each indicator will be part of the RECUIMA (REgistro CUbano de Infarto Agudo de MiocArdio $\lbrace$ {Cuban Registry of Myocardial Infarction} $\rbrace$ ) datasheet, as the authors believe this will increase the information gathered. A clear numerator and denominator were identified for each PM to ensure accurate measurement of the indicator upon application in routine clinical practice.

2.3. Selection of panel members

In reviewing the nomination of expert panel members for assessing potential PM and developing a final set, investigators took into consideration allowing the Cuban Society of Cardiology and Cuban National Group of Cardiology to make the selection, as this document would be representative of these two groups. No criteria selection was informed to maintain this selection as primary suggested. Still, panel members were selected from different institutions, including university hospitals, general hospitals, and other clinical settings. Investigators then contacted the selected nominees to assess their interest and availability for this study. Of the selected panel members, 15 were 2nd Degree Specialists in Cardiology (Cuban categorization that implies higher performance as a cardiologist), 9 had a teaching category equal to or higher than Assistant Professor; 3 had a Doctor of Science Degree, and the remaining 10 had a master’s degree. They all have an average of 26.8 ± 11 years of experience as cardiologists.

2.4. Consensus through a modified delphi method

A modified Delphi technique (the RAND Corporation [RAND]/University of California Los Angeles Appropriateness Method) was used to arrive at the final set of PMs (Fig. 1). Survey sheets were adapted to include parameters suggested by the American College of Cardiology/American Heart Association Task Force on Performance Measures document. Based on this technique, consensus building was done by panel members in 2 rounds. However, the initial set of PMs was extensive, with up to 84 from 6 associations, and several added by members of the Writing Committee were gathered.

Fig. 1.

Modified Delphi technique to determine final set of PMs.

These members were also responsible for the first removal of duplicate PMs and those which were impossible to adapt to the conditions of Cuban networks (and overall low/middle income settings), such as those related to coronary intervention and transfer of patients to PCI-capable hospitals. In the first Delphi Round, potential indicators (88) were individually rated using a 5-point scale (1 being the lowest, 5 being the highest) by members of the Writing Panel (5 members), to detect not applicable PMs, until all of them were discharged.

During the 2nd round, potential QIs were submitted to each panel member. Each member was asked to rate each potential QI using the same scale. After, during a Third Delphi Round, selected indicators (19) were critically individually rated using the same questionnaire and scale from the previous round. When the expert panel members felt the need, they proposed minor additions, deletions, or modifications to the set of potential QIs, which had to be approved by three or more of the Writing Panel members before presentation to other expert panel members.

Then, both potential QIs were voted to ultimately accept only one or none of them. No expert panel members knew the results of any other member at any stage of the process. Finally, indicators that had an average score higher than 4.5 points without significant disagreement (assumed from the standard deviation) were included in the final set of PMs. Disagreement was defined as a difference in punctuation greater than 2 standard deviations.

3. Results

All measures (Pre-Hospital Electrocardiogram; Patients with reperfusion therapy; Pre-hospital Reperfusion; Ischemic time less than 120 minutes; System delay time less than 90 minutes; In-hospital Mortality; Complete in-hospital Treatment; Complete in-hospital Treatment in patients with Heart Failure; 30 day-Re-admissions; 30 day-mortality; Patients with in-hospital stress test performed; and, Patients included in rehabilitation programs) (Table 1 and Supplementary Charts 1–12) were designed to assess the quality of care offered to patients with STEMI in Cuban inpatient settings. However, these measures may be applicable to other settings in low- and middle-income countries where standard treatment does not include coronary intervention.

Table 1
Selected performance and quality measures

No. Perfromance measure/quality metric Classification Responsable Domain of measure

PM-1 Pre-Hospital Electrocardiogram Admission Institution or provider CEC

PM-2 Patients with reperfusion therapy Admission Institution or provider CEC

PM-3 Pre-hospital Reperfusion Admission Institution or provider CEC

PM-4 Ischemic time less than 120 minutes Admission Institution CCC

PM-5 System delay time less than 90 minutes Admission Institution CCC

PM-6 In-hospital Mortality Admission Institution or provider CEC

PM-7 Complete in-hospital Treatment Admission Institution or provider CEC

PM-8 Complete in-hospital Treatment in patients with Heart Failure Admission Institution or provider CEC

PM-9 30 day-Re-admissions Follow-up Institution or provider CEC

PM-10 30 day-mortality Follow-up Institution or provider CEC

QM-1 Patients with in-hospital stress test performed Admission Institution or provider CEC and CCC

QM-2 Patients included in rehabilitation programs Follow-up Institution or provider CEC and CCC

No.	Perfromance measure/quality metric	Classification	Responsable	Domain of measure
PM-1	Pre-Hospital Electrocardiogram	Admission	Institution or provider	CEC
PM-2	Patients with reperfusion therapy	Admission	Institution or provider	CEC
PM-3	Pre-hospital Reperfusion	Admission	Institution or provider	CEC
PM-4	Ischemic time less than 120 minutes	Admission	Institution	CCC
PM-5	System delay time less than 90 minutes	Admission	Institution	CCC
PM-6	In-hospital Mortality	Admission	Institution or provider	CEC
PM-7	Complete in-hospital Treatment	Admission	Institution or provider	CEC
PM-8	Complete in-hospital Treatment in patients with Heart Failure	Admission	Institution or provider	CEC
PM-9	30 day-Re-admissions	Follow-up	Institution or provider	CEC
PM-10	30 day-mortality	Follow-up	Institution or provider	CEC
QM-1	Patients with in-hospital stress test performed	Admission	Institution or provider	CEC and CCC
QM-2	Patients included in rehabilitation programs	Follow-up	Institution or provider	CEC and CCC

CCC: Communication and care coordination. ECC: Clinical effectiveness of care.

Each measure was designed to limit performance measurement to patients without a valid reason for exclusion from the measure. First, the official denomination and short name for day-to-day work were presented. Second, numerator and denominator characteristics were offered. Measure exclusions were the reasons that remove a patient from the denominator, regardless of whether they had been included in the numerator if the criteria had been fulfilled. In contrast to exclusions, denominator exceptions were those conditions that removed a patient from the denominator only if the criteria for the numerator were not met. This allows for a better understanding of several measures that will not be fulfilled despite the decision of health care providers.

The RECUIMA is expected to be active in every Coronary Intensive Care in Cuba in the near future, and attending physicians may have a real-time data source to self-feedback and detect early changes in prescription rates or times of assistance, such as during the current COVID-19 pandemic.

Several other inherent attributes of these measures are also presented: measures units, domain, objective, and data storage location. The measures’ units will mostly be percentages, although some may use minutes because they involve time measurements. The domain refers to one of the domains of quality: structure, process, and outcome. Each measure has only one domain. The objective indicates which part of the care is measured: Effectiveness of care, for those processes which directly involve health care providers, or Intercommunication and coordination, in the case of transfers or those processes that involve policy makers.

Finally, adoption reasons, as well as clinical recommendations, were shown. In the Adoption Reasons section, information concerning performance measures from AHA/ACC Clinical Performance and Quality Measures, ESC Guidelines for the management of STEMI, Australian Clinical Guidelines for the Management of Coronary Syndromes, and National Clinical Guideline Centre for management of STEMI is presented. Shortly after, due to the lack of a clinical practice guideline for the management of AMI in Cuba, some recommendations are given to achieve proper treatment of these patients.

4. Discussion

At this time, there are two major running projects based in gathered data from Cuban Registry of Myocardial Infarction [30,31]. And one of them directly involves PM. Writing panel members recognize that this set of measures is not perfect, and will evolve as works with these measures may change practice of Cardiology in the country. Also, as stated previously, this set was not created to start a competition among cardiac centers, but to allow an increase in quality of attention of patients with AMI [32]. These measures open a new window to start several projects that may be presented in any format the author chooses, at conferences or other scientific activities, or through publication using data from their centers.

Researchers can present in conferences or other scientific activities, or publish using data from their centers without having to send a request to the Writing Committee [32]. If a major research is proposed, that may need all the registration data and with other data that include any other center or territory, Writing Committee is willing to receive proper documentation to give permission.

PMs provide a clear and validated set of measures for systematic evaluation of quality of medical care for a specific disease process or procedure at hospital level. They are not intended to report the best performance in ideal situations; but the average reached in real-world situations [32].

By collecting and reporting these measures and joining national registries, hospitals can compare their performance against centers in their region or nation. Measurement and benchmarking are critical and necessary first steps to improve patient quality and outcomes, as a tool to objectively assess quality [2]. This facilitates the identification of quality gaps and opportunities for improvement, which are critical and necessary first steps to improving patient quality and outcomes. They should be increasingly used in quality assessment, public information, and development of care plans.

This study has its own inherent limitations. First, the participants in the Delphi Panel may have their own biases and perspectives, focusing on a specific aspect of STEMI care, which may not provide a comprehensive picture of the overall performance measures. Second, several relevant stakeholders such as patients or healthcare providers such as nurses, or primary care doctors were not included in the panel. Finally, this set of performance measures can only be extended to scenarios where invasive procedures are not performed as the usual therapy in STEMI.

5. Conclusion

Performance measures are a powerful tool to identify gaps and opportunities to improve quality and provide a clear path forward to provide high-quality, responsible health care. This document provides an official set of PMs for the attention of patients with ST segment Elevation Myocardial Infarction of Cuban Society of Cardiology and Cuban National Group of Cardiology.

Footnotes

Acknowledgements

Dr. Rodríguez-Ramos and Dr. Santos-Medina would like to thank the Expert Panel Members (listed in alphabetical order): Gilberto Cairo-Sáez, MD, PhD^{1, a}; Leonardo Lopez- Ferrero MD, FACC^{2, b}; Manuel Lage-Meneses MD^{1, c}; Mirta López MD^{1, d}; Lázaro Mata, MD^{1, e}; Varinia Montero, MD FACC^{2, f}; Reinaldo de la Noval-García MD FACC^{2, g}; Ángel Obregón-Santos, MD, FACC^{2, h}; Mirta Pérez-Yanes, MD^{2, i}; Abel Salas, MD^{1, j}; Jesús Satorre-Igualada, MD^{1, k}; Elizabeth Sellen-Sanchen, MD^{1, l}.

(1) Member of the Panel of Experts of the Cuban National Group of Cardiology. (2) Member of the panel of Experts of the Cuban Society of Cardiology. (a) Department of Internal Medicine, Marta Abreu University Polyclinic, Santa Clara, Villa Clara, Cuba. (b) Interventional Cardiology Department. Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba. (c) Cardiology Department, “Camilo Cienfuegos” General Hospital, Sancti-Spiritus, Cuba. (d) Coronary Care Unit, Hermanos Ameijeiras CardioCentro, Hermanos Ameijeiras Hospital, Havana, Cuba. (e) Cardiology Department, Hospital Martires de 9 de Abril, Sagua La Grande, Villa Clara, Cuba. (f) Cardiology Department, Agostinho Neto Hospital, Guantánamo, Cuba. (g) Department of Preventive Cardiology, Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba. (h) Interventional Cardiology Department, Hermanos Ameijeiras CardioCentro, Hermanos Ameijeiras Hospital, Havana, Cuba. (i) Hermanos Ameijeiras Cardiovascular Cardiovascular Rehabilitation Department, Hermanos Ameijeiras Hospital, Havana, Cuba. (j) Interventional Cardiology Department, CardioCentro Ernesto Guevara, Santa Clara, Villa Clara, Cuba. (k) Interventional Cardiology Department, Ernesto Guevara Cardio Center, Santa Clara, Villa Clara, Cuba. (l) Cardiology Department, Amalia Simoni Hospital, Camagüey, Cuba.

Conflict of interest

None to report.

Funding

This research did not receive any specific grant from agencies in the public, commercial, or non-profit sectors.

Supplementary materials

The charts are available from .

References

Vogel

Claessen

Arnold

Chan

Cohen

Giannitsis

ST-segment elevation myocardial infarction. Nat Rev Dis Primers. 2019;5(1):39. doi:10.1038/s41572-019-0090-3.

Pendyal

Rothenberg

Scofi

Krumholz

Safdar

Dreyer

National trends in emergency department care processes for acute myocardial infarction in the United States, 2005 to 2015. J Am Heart Assoc. 2020;9(20):e017208. doi:10.1161/JAHA.120.017208. Epub 2020 Oct.

Chew

Scott

Cullen

French

Briffa

Tideman

on behalf of NHFA/CSANZ. ACS Guideline 2016 Executive Working Group: National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the management of acute coronary syndromes 2016. Heart Lung Circ. 2016;25(9):895–951. doi:10.1016/j.hlc.2016.06.789.

2020 Update of 2014 NICE acute coronary syndromes in adults. Quality standard. Available from: https://www.nice.org.uk/guidance/qs68/resources/acute-coronary-syndromes-in-adults-pdf-2098794360517. Accessed September 2020.

Ibanez

James

Agewall

Antunes

Bucciarelli-Ducci

Bueno

on behalf of the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC): 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119–77. doi:10.1093/eurheartj/ehx393.

O’Gara

Kushner

Ascheim

Casey

Chung

de Lemos

2013 ACCF/AHA Guideline for the management of ST-Elevation myocardial infarction. A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;127(1):1–57. doi:10.1161/CIR.0b013e3182742cf6.

Timoteo

Mimoso

. Assessment of quality performance measures in patients with acute coronary syndromes: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS), a nationwide registry. J EvalClinPract. 2018;1–8.

Barbayannis

Chiu

Sargsyan

Cabrera

Beavers

Kostis

Relation between statewide hospital performance reports on myocardial infarction and cardiovascular outcomes. Am J Cardiol. 2019;123:1587–94.

Hess

Gunzburger

Kini

Liu

Jones

Matlock

National trends of hospital performance in acute myocardial infarction care. Circ Cardiovasc Qual Outcomes. 2018;11:e004282. doi:10.1161/CIRCOUTCOMES.117.004282.

10.

Desai

Udell

Wang

Spatz

Dharmarajan

Ahmad

Trends in performance and opportunities for improvement on a composite measure of acute myocardial infarction care. Circ Cardiovasc Qual Outcomes. 2018;11(4):e004282. doi:10.1161/CIRCOUTCOMES.117.004282.

11.

Downing

Wang

Dharmarajan

Nuti

Murugiah

Quality of care in Chinese hospitals: Processes and outcomes after ST-segment elevation myocardial infarction. Am Heart Assoc. 2017;6:e005040. doi:10.1161/JAHA.116.005040.

12.

Caixeta

Franken

Katz

Lemos

Gomes

Yokota

PKO

Benchmarking as a quality of care improvement tool for patients with ST-elevation myocardial infarction: An NCDR ACTION Registry experience in Latin America. Int J Qual Health Care. 2020;32(1):A1–A8. doi:10.1093/intqhc/mzz115; PMID: 31832665.

13.

Van Veghel

Daeter

Bax

Amoroso

Blaauw

Camaro

Organization of outcome-based quality improvement in Dutch heart centres. Eur Heart J Qual Care Clin Outcomes. 2020;6(1):49–54. doi:10.1093/ehjqcco/qcz021.

14.

Bhatt

Krishnamurthy

. Quality improvement through data registries. JACC. 2019;74(22):2796–8. doi:10.1016/j.jacc.2019.10.023.

15.

Bhatt

Drozda

Shahian

Chan

Fonarow

Heidenreich

ACC/AHA/STS statement on the future of registries and the performance measurement enterprise: A report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Society of Thoracic Surgeons. Ann ThoracSurg. 2015;100:1926–41.

16.

Masoudi

Bonow

Brindis

Cannon

DeBuhr

Fitzgerald

ACC/AHA 2008 statement on performance measurement and reperfusion therapy: A report of the ACC/AHA Task Force on Performance Measures (Work Group to Address the Challenges of Performance Measurement and Reperfusion Therapy). J Am Coll Cardiol. 2008;52:2100–12.

17.

Bonow

Masoudi

Rumsfeld

Delong

Estes 3rd

NAM

Goff

ACC/AHA classification of care metrics: Performance measures and quality metrics: A report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2008;52:2113–7.

18.

Schiele

Gale

Bonnefoy

Capuano

Claeys

Danchin

Editor’s choice-quality indicators for acute myocardial infarction: A position paper of the acute cardiovascular care association. Eur Heart J Acute Cardiovasc Care. 2017;6(1):34–59.

19.

Jneid

Addison

Bhatt

Fonarow

Gokak

Grady

2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non–ST-elevation myocardial infarction. J Am Coll Cardiol. 2017;70(16):2048–90. doi:10.1016/j.jacc.2017.06.032.

20.

Lopez-Sendon

Gonzalez-Juanatey

Pinto

Cuenca-Castillo

Bidamos

Dalmau

Quality markers in Cardiology: Measures of outcome and clinical practice—A perspective of the Spanish Society of Cardiology and of Thoracic and Cardiovascular Surgery. Cir Cardiov. 2015;22(6):315–24.

21.

Rodriguez-Ramos

. Increasing quality of secondary prevention of acute myocardial infarction by using E-Health. High Blood Press Cardiovasc Prev. 2018. doi:10.1007/s40292-018-0294-8.

22.

Delgado-Acosta

Gonzalez Orihuela

Monteagudo-Diaz

Hernandez-Carlsen

Leiva-García

Saavedra Marques

. Calidad de la atención médica a pacientes con infarto agudo del miocardio. Cienfuegos 2013. Finlay. 2016;6(1):3–11.

23.

Spertus

Eagle

Krumholz

Mitchell

Normand

SLT

. American College of Cardiology and American Heart Association Methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. J Am Coll Cardiol. 2005;45:1147–56.

24.

Guha

Sethi

Ray

Bahl

Shanmugasundaram

Cardiological Society of India: Position statement for the management of ST segment elevation myocardial infarction in India. Indian Heart J. 2017;69 Suppl 1(Suppl 1):S63–97. doi:10.1016/j.ihj.2017.03.006.

25.

China Society of Cardiology of Chinese Medical Association Editorial Board of Chinese Journal of Cardiology. Guideline for diagnosis and treatment of patients with ST-elevation myocardial infarction. Zhonghua Xin Xue Guan Bing Za Zhi. 2010;38:675–90.

26.

Ozaki

Katagiri

Onuma

Amano

Takashi Muramatsu

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018. Cardiovasc Interv Ther. 2018;33(2):178–203. doi:10.1007/s12928-018-0516-y.

27.

Wong

Welsford

Ainsworth

Abuzeid

Fordyce

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST- Elevation Myocardial Infarction: Focused update on regionalization and reperfusion. Can J Cardiol. 2019;35(2):107–32. doi:10.1016/j.cjca.2018.11.031.

28.

Chandrashekhar

Alexander

Mullasari

Kumbhani

Alam

Resource and infrastructure-appropriate management of ST-segment elevation myocardial infarction in low- and middle-income countries. Circulation. 2020;141(24):2004–25. doi:10.1161/CIRCULATIONAHA.119.041297.

29.

Kontsevaya

Bates

Schirmer

Bobrova

Leon

McKee

. Management of patients with acute ST-segment elevation myocardial infarction in Russian hospitals adheres to international guidelines. Open Heart. 2020;7(1):e001134. doi:10.1136/openhrt-2019-001134.

30.

Martinez-Garcia

Rodriguez-Ramos

Santos-Medina

Carrero-Vazquez

Chipi-Rodriguez

. New model predicts in-hospital complications in myocardial infarction. Discoveries (Craiova). 2022;10(1):e142. doi:10.15190/d.2022.1. PMID: 36133173; PMCID: PMC 9482690.

31.

Rodriguez-Ramos

Cairo-Saez

Prohias-Martinez

. Quality evaluation in delivering care for acute myocardial infarction in Sancti-Spirítus, Cuba. Cardiol Belarus. 2022;14(1):6–16.

32.

Rodríguez-Ramos

. Observation of performance measures of STEMI in elderly after implementation of an updated protocol: Results from a single center without coronary interventions. J Geriatr Cardiol. 2022;19(11):930–6. doi:10.11909/j.issn.1671-5411.2022.11.012. PMID: 36561060; PMCID: PMC9748268.