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ACC/AHA/AHRQ/CMS/JCAHO Practice Advisory

Commitment to Respond to COMMIT/CCS-2 Trial Beta Blocker Use for Myocardial Infarction (MI) Within 24 Hours of Hospital Arrival

April 27, 2005

At the American College of Cardiology Annual Scientific Session '05 in Orlando, the COMMIT/CCS-2 trial results evaluating the use of metoprolol for the emergency treatment of ST elevation myocardial infarction were presented. As the largest clinical trial ever undertaken in China and the second largest trial ever conducted in this patient population in the world, the preliminary results have raised questions about the use of beta blockers (IV then oral dosing) in the early stages of MI, especially in Killip Class II and III heart failure patients.

The American College of Cardiology, American Heart Association, Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid Services, and the Joint Commission on Accreditation of Healthcare Organizations have begun an initial review of the presentation findings from the COMMIT/CCS-2 trial. In support of national efforts to develop a common set of performance measures, discussions of the impact of this trial on the intent and specifications for the relevant measure are being undertaken jointly.

Since all the details of the methodology and the final results from COMMIT/CCS-2 are not yet available nor peer reviewed and published, it is too early to state definitively whether or not changes will be required for performance measure specifications. The practicing community is reminded to review the current guidelines and performance measure specifications. These documents contain important information about contraindications and exclusion criteria for the use of beta blockers early in patients presenting with MI. (Select for Fact Sheet.) Users of the measures are reminded that the measures have been constructed to allow for clinical judgment and documentation of reasons for not prescribing beta blockers. As such, the specifications are meant to encourage evidence-based care and to help clinicians avoid care oversights but do not mandate that everyone is treated in exactly the same way.

It is important to remember that a number of other trials have been conducted in this area and are currently reflected in both the guidelines and performance measures. Each patient should be evaluated in the context of all the information that has been published in the medical literature and in the current statements of the organizations represented in this advisory. It should be emphasized that beta blockers have been shown to provide important benefits to MI patients in the long term, a fact reinforced by the findings from the COMMIT/CCS-2 trial.

Our organizations are committed to issuing a timely response to this emerging evidence to ensure that relevant guidelines and performance measures reflect the current state of the science and support optimal patient care. Building upon relationships formed last year in updating the ACE inhibitor therapy measures to include angiotensin receptor blockers (ARBs), our organizations have begun an ongoing dialog to ensure that information is shared, evaluated, and responded to with a unified, timely and thorough response to clinical issues, such as those raised by this trial.

If further information or important patient safety issues are raised during our review prior to publication of the trial, an additional advisory will be issued. A final follow-up statement will be released shortly after the publication of the COMMIT/CCS-2 trial results advising the community about the findings from our review and its impact on performance measurement specifications.

Evidence-based medicine, as well as the guidelines and performance measures which derive from its foundation, have had a transformational effect on improving health care for all patients for more than a decade. However, each new trial reminds all stakeholders as clinical evidence changes, guidelines and measures must be continually reexamined. The ultimate goal is never simply to treat to a prescribed number but rather to achieve excellence by perfecting the care of each individual patient.

American College of Cardiology Foundation
American Health Association
Agency for Healthcare Research and Quality
Centers for Medicare & Medicaid Services
Joint Commission of Healthcare Organizations

April 2005

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