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Coronary Artery Disease (CAD)
© Optum, Inc. 2015
EBM Connect Clinical Expert Panel review: 1/17/14
Confidential
Disease Management
R-1
Patient(s) currently taking a statin.
9000002
Statin medications are indicated for all patients with atherosclerosis unless contraindicated
or not tolerated. This is a Class I* recommendation from the 2012
ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guidelines (1). According to the 2013 ACC/AHA
guidelines on the treatment of blood cholesterol, statins are recommended in women and
men with clinical atherosclerotic cardiovascular disease (ASCVD) who are 75 years of age
and younger (Class I* recommendation) (1). Additionally, statins should be considered in
patients with clinical ASCVD who are older the 75 years of age (Class IIa* recommendation)
particularly in those already on treatment who are tolerating it. Statins cause a 25% (16-50%)
reduction in events including overall mortality, recurrent myocardial infarction, unstable
angina episodes, stroke, need for revascularization, and hospitalization (3).
Statins may be contraindicated or not tolerated by some patients (1,2). Patients should not
take a statin if they have had rhabdomyolysis with previous statin use (4). Statins may be
contraindicated for some patients with abnormal liver tests (4). Statins are contraindicated
during pregnancy (5). Given the limitations of claims data, it is not possible to reliably
identify contraindications or previous adverse events.
*The ACC/AHA guideline recommendation format for classifying indications and
summarizing both the evidence and expert opinions is as follows (1):
Class I: Conditions for which there is evidence for and/or general agreement that the
procedure or treatment is useful and effective.
Class II: Conditions for which there is conflicting evidence and/or divergence of opinion
about the usefulness/efficacy of a procedure or treatment.
Class IIa: The weight of evidence or opinion is in favor of the procedure or treatment.
Class IIb: Usefulness/efficacy is less well established by evidence or opinion.
Class III: Conditions for which there is evidence and/or general agreement that the
procedure or treatment is not useful/effective and in some cases may be harmful.
1.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS
Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart
Disease: Executive Summary: A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines, and the
American College of Physicians, American Association for Thoracic Surgery, Preventive
Cardiovascular Nurses Association, Society for Cardiovascular Angiography and
Interventions, and Society of Thoracic Surgeons. Circulation 2012;126:3097-3137.
2.
Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH,
Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST,
Smith SC Jr, Watson K, Wilson PWF. 2013 ACC/AHA guideline on the treatment of
blood cholesterol to reduce atherosclerotic
cardiovascular risk in adults: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. Circulation. 2013;00:000–000.
3.
Heart Protection Study. Lancet 2002;360:7-22.
4.
Pasternak RC, Smith SC, Jr., Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C.
ACC/AHA/NHLBI Advisory on the Use and Safety of Statins. J Am Coll Cardiol
2002;40:567-72.
5.
HMG-CoA Reductase Inhibitors. Drug Facts and Comparisons. eFacts [online].
2014. Available from Wolters Kluwer Health, Inc. Accessed January 17, 2014.
R-2
9000001
Patient(s) currently taking an ACE-inhibitor or angiotensin receptor blocker (ARB).
ACE-inhibitor or angiotensin receptor blocker (ARB) therapy is recommended for patients
with coronary artery disease (CAD) unless otherwise contraindicated or not tolerated
(1,2). This is a Class I* recommendation from the 2012
ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guidelines (1). ACE-inhibitor therapy should be
considered in all other patients with stable ischemic heart disease and other vascular
disease, a Class IIa* recommendation (1). ARB therapy is recommended in ACE-I intolerant
patients who are otherwise candidates for ACE-I therapy, a Class I or IIa* recommendation,
depending on other comorbidities (1).
ACE-I therapy is beneficial in all patients with atherosclerosis even if the blood pressure and
ejection fraction are normal. In the HOPE trial, ACE-inhibitor use versus placebo resulted in a
20% reduction in myocardial infarctions, 32% reduction in strokes, and 16% reduction in
overall mortality; all results were statistically significant (3). Additional benefits of ACEinhibitor use demonstrated in the HOPE trial included significant reductions in congestive
heart failure, new cases of diabetes mellitus, diabetic complications, revascularization
procedures, and cardiac deaths (3).
ACE-inhibitors may be contraindicated or not tolerated by some patients (4). ACE-inhibitors
should not be prescribed to patients who have experienced life-threatening adverse
reactions (e.g., angioedema) during previous exposure to the drug. ACE-inhibitors are
contraindicated during pregnancy and should be prescribed with caution in patients with
very low systemic blood pressures (systolic blood pressures less than 80mm Hg), markedly
elevated serum creatinine levels (creatinine greater than 3 mg/dL), bilateral renal artery
stenosis, or elevated levels of serum potassium (greater than 5.5 mmol/L) (4). Additional
codes, such as
CPT Category II codes, are used in this measure to identify ACE-I or ARB therapy as well as
exclusions to this therapy. However, given the limitations of claims data, it is not possible to
reliably identify all contraindications to ACE-I or ARB therapy.
*The ACCF/AHA guideline recommendation format for classifying indications and
summarizing both the evidence and expert opinions is as follows (1):
Class I: Conditions for which there is evidence for and/or general agreement that the
procedure or treatment is useful and effective.
Class II: Conditions for which there is conflicting evidence and/or divergence of opinion
about the usefulness/efficacy of a procedure or treatment.
Class IIa: The weight of evidence or opinion is in favor of the procedure or treatment.
Class IIb: Usefulness/efficacy is less well established by evidence or opinion.
Class III: Conditions for which there is evidence and/or general agreement that the
procedure or treatment is not useful/effective and in some cases may be harmful.
1.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS
Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart
Disease: Executive Summary: A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines, and the
American College of Physicians, American Association for Thoracic Surgery, Preventive
Cardiovascular Nurses Association, Society for Cardiovascular Angiography and
Interventions, and Society of Thoracic Surgeons. Circulation 2012;126:3097-3137.
2. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC Guidelines for Secondary Prevention for
Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update:
Endorsed by the National Heart, Lung, and Blood Institute. J. Am. Coll. Cardiol
2006;47:2130-39.
3. Heart Outcomes Prevention Evaluation Study. NEJM 2000;342:145-153.
4.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC,
Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA,
McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW,
Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of
heart failure: a report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–
e327.
Care Pattern
CP-I
Patient(s) that did not have a CAD related emergency department encounter in last 12
9000020 reported months.
This measure identifies patients evaluated in the emergency department with a primary
diagnosis of coronary artery disease. It could be used to support care coordination, identify
high risk patients, identify potential health care quality problem areas, or support other
quality program initiatives. This measure was developed using the EBM Connect consultant
panel process.