JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO.

-, 2020
ª 2020 AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION AND
AMERICAN HEART ASSOCIATION, INC

PERFORMANCE MEASURES

2020 Update to the 2016 ACC/AHA

Clinical Performance and
Quality Measures for Adults With
Atrial Fibrillation or Atrial Flutter
A Report of the American College of Cardiology/American Heart Association
Task Force on Performance Measures

Developed in Collaboration With the Heart Rhythm Society

Writing Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair David D. McManus, MD, MS, FACC, FAHA, FHRS
Committee Robert L. McNamara, MD, MHS, FACC, FAHA
Members N. A. Mark Estes III, MD, FACC, FAHA
Gregg C. Fonarow, MD, FACC, FAHA*
*ACC/AHA Task Force on Performance Measures Liaison.
Corrine Y. Jurgens, PHD, RN, ANP, FAHA
yHeart Rhythm Society Representative.
Michelle M. Kittleson, MD, PHD, FACC
Joseph E. Marine, MD, MBA, FACC, FHRSy

ACC/AHA Task P. Michael Ho, MD, PhD, FACC, FAHA, Chairz Christopher Lee, PhD, RN, FAHAx
Force on Leo Lopez, MD, FACC, FAHAz
Performance H. Vernon Anderson, MD, FACCz Jeffrey W. Olin, DO, FACC, FAHAx
Measures Ankeet S. Bhatt, MD, MBAz Manesh R. Patel, MD, FACCx
Biykem Bozkurt, MD, PhD, FACC, FAHAx Faisal Rahman, BM BChz
Sandeep Das, MD, MPH, FACCx Katherine B. Salciccioli, MDx
Joao F. Monteiro Ferreira, MD, PhD, FACCz Boback Ziaeian, MD, PhD, FACC, FAHAz
Gregg C. Fonarow, MD, FACC, FAHA, Ex Officiox
Stacy Garcia, RT(R), RN, BSN, MBA-HCMz
zAmerican College of Cardiology Representative.
Michael E. Hall, MD, MS, FACC, FAHAx
xAmerican Heart Association Representative.
Hani Jneid, MD, FACC, FAHAx

This Physician Performance Measurement Set (PPMS) and related data specifications were developed by the Physician Consortium for Performance
Improvement (the Consortium), including the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical
Association (AMA), to facilitate quality-improvement activities by physicians. The performance measures contained in this PPMS are not clinical
guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. Although copyrighted, they can be
reproduced and distributed, without modification, for noncommercial purposes, for example, use by health care providers in connection with their
practices. Commercial use is defined as the sale, license, or distribution of the performance measures for commercial gain, or incorporation of the
performance measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the PPMS require a license
agreement between the user and the AMA (on behalf of the Consortium) or the ACC or the AHA. Neither the AMA, ACC, AHA, the Consortium, nor its
members shall be responsible for any use of this PPMS.
The measures and specifications are provided “as is” without warranty of any kind.
Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary
licenses from the owners of the code sets. The AMA, the ACC, the AHA, the National Committee for Quality Assurance (NCQA), and the Physician
Consortium for Performance Improvement (PCPI) and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT)
or other coding contained in the specifications.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2020.08.037

2 Heidenreich et al. JACC VOL. -, NO. -, 2020
2020 ACC/AHA Atrial Fibrillation Measure Update -, 2020:-–-

TABLE OF CONTENTS

TOP 5 TAKE-HOME MESSAGES . . . . . . . . . . . . . . . . . . . . - APPENDIX C

Reviewer Relationships With Industry and Other

PREAMBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Entities (Comprehensive) . . . . . . . . . . . . . . . . . . . . . . . . -

1. DECISION TO UPDATE THE ATRIAL

TOP 5 TAKE-HOME MESSAGES FOR UPDATE OF
FIBRILLATION MEASURE ON
ADULTS WITH ATRIAL FIBRILLATION OR ATRIAL
ANTICOAGULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . -
FLUTTER
1.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
1. This document describes updates to the atrial fibrilla-
2. ACC/AHA UPDATED ATRIAL FIBRILLATION
tion performance measures that are appropriate for
MEASURE ON ANTICOAGULATION AND UPDATED
public reporting or pay-for-performance programs.
PERFORMANCE MEASURES . . . . . . . . . . . . . . . . . . . . . -
2. The performance measures are taken from the 2019
2.1. Discussion of Changes to the Atrial Fibrillation American College of Cardiology/American Heart Asso-
Measure on Anticoagulation . . . . . . . . . . . . . . . . . . . - ciation/Heart Rhythm Society atrial fibrillation guide-
line update and are selected from the strongest
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - recommendations (Class 1 or 3).
3. Quality measures are provided that are not yet ready
APPENDIX A
for public reporting or pay-for-performance programs
Updated Atrial Fibrillation Measures . . . . . . . . . . . . . . . - but might be useful for clinicians and healthcare or-
Short Title: PM-1: CHA2DS2-VASc Risk Score ganizations for quality improvement.
Documented Prior to Discharge . . . . . . . . . . . . . . . . - 4. The recent guideline change regarding the definition of
Short Title: PM-2: Anticoagulation Prescribed valvular atrial fibrillation is now incorporated into the
Prior to Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . - performance measures. This includes patients with
Short Title: PM-3: PT/INR Planned Follow-Up moderate or severe mitral stenosis and those with a
Documented Prior to Discharge for Warfarin mechanical prosthetic heart valve.
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 5. The recent guideline changes regarding different
Short Title: PM-4: CHA2DS2-VASc Risk Score CHA 2DS2 -VASc risk score treatment thresholds for men
Documented (Outpatient) . . . . . . . . . . . . . . . . . . . . . -
(>1) and women (>2) are now incorporated into the
Short Title: PM-5: Anticoagulation Prescribed performance measures.
(Outpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
PREAMBLE
APPENDIX B
The American College of Cardiology (ACC)/American
Author Relationships With Industry and
Heart Association (AHA) performance measurement sets
Other Entities (Relevant) . . . . . . . . . . . . . . . . . . . . . . . . . -
serve as vehicles to accelerate translation of scientific

CPT contained in the measures specifications is copyright 2004–2012 American Medical Association. LOINC copyright 2004–2012
Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT) copyright 2004–2012 International Health
Terminology Standards Development Organization. All rights reserved.
This document underwent a 14-day peer review between April 16, 2020, and May 1, 2020.
This document was approved by the American College of Cardiology Clinical Policy Approval Committee on June 29, 2020; by the
American Heart Association Science Advisory and Coordinating Committee on July 16, 2020; the American Heart Association Executive
Committee on August 10, 2020; and by the Heart Rhythm Society on August 6, 2020.
The American College of Cardiology requests that this document be cited as follows: Heidenreich PA, Estes NAM 3rd, Fonarow GC, Jurgens
CY, Kittleson MM, Marine JE, McManus DD, McNamara RL. 2020 Update to the 2016 ACC/AHA clinical performance and quality measures for
adults with atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on
Performance Measures. J Am Coll Cardiol 2020;CCC:CCCC–CCCC.
This article has been copublished in the Circulation: Cardiovascular Quality and Outcomes.
Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart As-
sociation (professional.heart.org). For copies of this document, please contact Elsevier Inc.’s Reprint Department via fax (212-633-3820) or
email ([email protected]).
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the
express permission of the American College of Cardiology. Please contact Elsevier’s permission department at https://www.elsevier.com/
about/policies/copyright/permissions.
JACC VOL. -, NO. -, 2020 Heidenreich et al. 3
-, 2020:-–- 2020 ACC/AHA Atrial Fibrillation Measure Update

evidence into clinical practice. Measure sets developed by accordance with the 2019 AHA/ACC/Heart Rhythm Society
the ACC/AHA are intended to provide practitioners and (HRS) atrial fibrillation guideline update (4).
institutions that deliver cardiovascular services with tools
to measure the quality of care provided and identify op- 2. ACC/AHA UPDATED ATRIAL FIBRILLATION
portunities for improvement. MEASURE ON ANTICOAGULATION AND
Writing committees are instructed to consider the UPDATED PERFORMANCE MEASURES
methodology of performance measure development (1,2)
and to ensure that the measures developed are aligned 2.1. Discussion of Changes to the Atrial Fibrillation Measure
with ACC/AHA clinical practice guidelines. The writing on Anticoagulation
committees also are charged with constructing measures
There were 2 changes to the performance measures, both
that maximally capture important aspects of care quality,
prompted by recent changes to the 2019 AHA/ACC/HRS
including timeliness, safety, effectiveness, efficiency,
atrial fibrillation guideline update (4). The first, which
equity, and patient-centeredness, while minimizing,
impacts all the performance measures (see Appendix A,
when possible, the reporting burden imposed on hospi-
for the changes and measure specifications), is the clari-
tals, practices, and practitioners.
fication that valvular atrial fibrillation is atrial fibrillation
Potential challenges from measure implementation
with either moderate or severe mitral stenosis or a me-
may lead to unintended consequences. The manner in
chanical heart valve. The second change is the separation
which challenges are addressed is dependent on several
of a male and female threshold for the CHA2 DS2-VASc
factors, including the measure design, data collection
score. This only applies to PM-5: Atrial Fibrillation/Atrial
method, performance attribution, baseline performance
Flutter: Anticoagulation Prescribed.
rates, reporting methods, and incentives linked to these
reports.
The ACC/AHA Task Force on Performance Measures STAFF
(Task Force) distinguishes quality measures from perfor-
mance measures. Quality measures are those metrics that American College of Cardiology

may be useful for local quality improvement but are not Athena Poppas, MD, FACC, President

yet appropriate for public reporting or pay for perfor- Cathleen Gates, Interim Chief Executive Officer

mance programs (uses of performance measures). New John S. Rumsfeld, MD, PhD, FACC, Chief Science and

measures are initially evaluated for potential inclusion as Quality Officer

performance measures. In some cases, a measure is Lara Slattery, Division Vice President, Clinical Registry

insufficiently supported by the guidelines. In other in- and Accreditation

stances, when the guidelines support a measure, the Grace Ronan, Team Lead, Clinical Policy Publication

writing committee may feel it is necessary to have the Timothy W. Schutt, MA, Clinical Policy Analyst

measure tested to identify the consequences of measure American College of Cardiology/American Heart Association

implementation. Quality measures may then be promoted Abdul R. Abdullah, MD, Director, Guideline Science and

to the status of performance measures as supporting ev- Methodology

idence becomes available. Rebecca L. Diekemper, MPH, Guideline Advisor,

P. Michael Ho, MD, PhD, FACC, FAHA Performance Measures

Chair, ACC/AHA Task Force on Performance Measures American Heart Association

Mitchell S.V. Elkind, MD, MS, FAAN, FAHA, President
1. DECISION TO UPDATE THE ATRIAL Nancy Brown, Chief Executive Officer
FIBRILLATION MEASURE ON Mariell Jessup, MD, FAHA, Chief Science and Medical
ANTICOAGULATION Officer
Radhika Rajgopal Singh, PhD, Vice President, Office of
1.1. Background Science, Medicine and Health
In 2020, the Task Force convened the writing committee Johanna A. Sharp, MSN, RN, Science and Medicine
to begin the process of updating the atrial fibrillation Advisor, Office of Science, Medicine and Health
measure on chronic anticoagulation therapy from the Melanie Shahriary, RN, BSN, Senior Manager,
2016 atrial fibrillation measure set (3). The writing com- Performance Metrics, Quality and Health IT
mittee was also charged with the task of identifying any Jody Hundley, Production and Operations Manager,
additional measures in need of updating to be in Scientific Publications, Office of Science Operations
4 Heidenreich et al. JACC VOL. -, NO. -, 2020
2020 ACC/AHA Atrial Fibrillation Measure Update -, 2020:-–-

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14. Lip GY, Tse HF, Lane DA. Atrial fibrillation. Lancet. 28. Hering D, Piper C, Bergemann R, et al. Thrombo-
3. Heidenreich PA, Solis P, Estes NAM 3rd, et al. 2016 2012;379:648–61. embolic and bleeding complications following St. Jude
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4. January CT, Wann LS, Calkins H, et al. 2019 AHA/
guideline for the management of patients with valvular
ACC/HRS focused update of the 2014 AHA/ACC/HRS 16. Mason PK, Lake DE, DiMarco JP, et al. Impact of the
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8. Ziegler PD, Glotzer TV, Daoud EG, et al. Detection of versus warfarin in patients with atrial fibrillation. tional registry. Circ Arrhythm Electrophysiol. 2012;5:
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with stroke risk factors and usefulness of continuous 22. January CT, Wann LS, Alpert JS, et al. 2014 33. Flaker G, Ezekowitz M, Yusuf S, et al. Efficacy and
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11. Gage BF, Waterman AD, Shannon W, et al. Valida-
KEY WORDS ACC/AHA Performance Measures,
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atrial fibrillation, atrial flutter, performance
stroke: results from the National Registry of Atrial Part 2: oral anticoagulants. American Heart Associa-
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JACC VOL. -, NO. -, 2020 Heidenreich et al. 5
-, 2020:-–- 2020 ACC/AHA Atrial Fibrillation Measure Update

APPENDIX A. UPDATED ATRIAL FIBRILLATION MEASURES

SHORT TITLE: PM-1 CHA 2 DS 2 -VASc Risk Score Documented Prior to Discharge

PM-1: Atrial Fibrillation or Atrial Flutter: CHA 2 DS 2 -VASc Risk Score Documented Prior to Discharge

Measure Description: Percentage of patients, age $18 y, with AF or atrial flutter for whom a CHA2DS2-VASc risk score has been documented in the medical record.

Numerator n Patients with AF or atrial flutter for whom a CHA2 DS 2 -VASc risk score was documented prior to discharge
For patients with AF or atrial flutter, assessment of thromboembolic risk should include:
CHA2DS2-VASc Score

Congestive HF 1

Hypertension 1

Age 65-74 y 1

Age $75 y 2

Diabetes mellitus 1

Stroke, TIA, or thromboembolism 2

Vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) 1

Sex category (i.e., female) 1

Denominator All patients with AF or atrial flutter

Denominator Exclusions n Patients age <18 y

n Patients with moderate or severe mitral stenosis
n Patients with a mechanical prosthetic heart valve
n Patients with transient or reversible causes of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac
surgery)
n Patients who leave against medical advice
n Patients who die during hospitalization
n Patients who are on comfort care measures only
n Patients who are transferred to another acute care hospital
n Patients with another indication for anticoagulation

Denominator Exceptions n Documentation of a medical reason for not assessing risk factors and documenting the CHA 2DS 2-VASc score,
including present or planned left atrial appendage occlusion or ligation, hypertrophic cardiomyopathy, or
other reasons
n Documentation of patient preference for not receiving anticoagulation

Measurement Period Encounter

Sources of Data Medical record or other database (e.g., administrative, clinical, registry)

Attribution Measure reportable at the facility or physician level

Care Setting Inpatient

Rationale

AF, whether paroxysmal, persistent, or permanent, and whether symptomatic or silent, significantly increases the risk of thromboembolic ischemic stroke. AF increases
the risk of stroke 5-fold, and AF in the setting of mitral stenosis increases the risk of stroke 20-fold over that of patients in sinus rhythm. Atrial flutter also increases
the risk of stroke, and this risk increases with certain risk factors.
Thromboembolism occurring with AF is associated with a greater risk of recurrent stroke, more severe disability, and mortality (5). Silent AF is also associated with
ischemic stroke (6–9). The appropriate use of anticoagulant therapy and the control of other risk factors, including hypertension and hypercholesterolemia,
substantially reduce stroke risk.
One meta-analysis has stratified ischemic stroke risk among patients with AF using the following point scoring system (10): AF Investigators; CHA2DS2 (congestive heart
failure, hypertension, age $75 y, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism [doubled]), or CHA2DS2-VASc (congestive heart
failure, hypertension, age $75 y [doubled] (11), diabetes mellitus, prior stroke or TIA or thromboembolism [doubled], vascular disease, age 65–74 y, sex category).
Compared with the CHA2DS2 score (12), the CHA2DS2-VASc score for AF has a broader score range (0 to 9) and includes a larger number of risk factors (female sex, 65–
74 y of age, and vascular disease) (13,14).
The selection of an anticoagulant agent should be based on shared decision-making that takes into account risk factors, cost, tolerability, patient preference, potential
for drug interactions, and other clinical characteristics, including time in the INR therapeutic range if the patient has been on warfarin, irrespective of whether the AF
pattern is paroxysmal, persistent, or permanent.
Clinical Recommendation(s)
2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (4)
1. For patients with AF and an elevated CHA 2 DS2 -VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. Options
include:
Warfarin (Class 1, Level of Evidence: A) (15–17)
Dabigatran (Class 1, Level of Evidence: B) (18)
Rivaroxaban (Class 1, Level of Evidence: B) (19)
Apixaban (Class 1, Level of Evidence: B) (20), or Edoxaban (Class 1, Level of Evidence: B-R) (21)
MODIFIED: This recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of
CHA2 DS2 -VASc scores is specified in subsequent recommendations. The LOEs for warfarin, dabigatran, rivaroxaban, and apixaban have not been
updated for greater granularity as per the new LOE system (Section 4.1. in the 2019 AF Guideline (4)). The original text can be found in Section 4.1 of
the 2014 AF guideline (22). Additional information about the comparative effectiveness and bleeding risk of DOACs can be found in Section 4.2.2.2.

Continued on the next page

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APPENDIX A. CONTINUED

SHORT TITLE: PM-1 Continued

Clinical Recommendation(s)
2. DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in DOAC-eligible patients with AF (except with moderate or
severe mitral stenosis or a mechanical heart valve) (18–21). (Class 1, Level of Evidence: A)
NEW: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve. When the DOAC trials are considered as a group,
the direct thrombin inhibitor and factor Xa inhibitors were at least noninferior and, in some trials, superior to warfarin for preventing stroke and
systemic embolism and were associated with lower risks of serious bleeding.
3. Among patients treated with warfarin, the INR should be determined at least weekly during initiation of anticoagulant therapy and at least monthly when
anticoagulation (INR in range) is stable (23–25). (Class 1, Level of Evidence: A)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
4. In patients with AF (except with moderate or moderate or severe mitral stenosis or a mechanical heart valve), the CHA2 DS 2 -VASc score is recommended for
assessment of stroke risk (15–17). (Class 1, Level of Evidence: B)
MODIFIED: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve.
5. For patients with AF who have mechanical heart valves, warfarin is recommended (26–30). (Class 1, Level of Evidence: B)
6. Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or
permanent (31–34). (Class 1, Level of Evidence: B)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
7. In patients with AF, anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative
risks of stroke and bleeding, as well as the patient’s values and preferences. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
8. For patients with atrial flutter, anticoagulant therapy is recommended according to the same risk profile used for AF. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
9. Reevaluation of the need for and choice of anticoagulant therapy at periodic intervals is recommended to reassess stroke and bleeding risks. (Class 1, Level
of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”

All patients with exclusions are removed from the denominator. Patients with exceptions are removed from the denominator only if the numerator is not met.
ACC indicates American College of Cardiology; AF, atrial fibrillation; AHA, American Heart Association; DOAC, direct-acting oral anticoagulant; HF, heart failure; HRS, Heart Rhythm
Society; INR, international normalized ratio; LOE, level of evidence; PM, performance measure; and TIA, transient ischemic attack.
JACC VOL. -, NO. -, 2020 Heidenreich et al. 7
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APPENDIX A. CONTINUED

SHORT TITLE: PM-2 Anticoagulation Prescribed Prior to Discharge

PM-2: Atrial Fibrillation or Atrial Flutter: Anticoagulation Prescribed Prior to Discharge

Measure Description: Percentage of patients, age $18 y, with AF or atrial flutter who were discharged on an FDA-approved anticoagulant drug for the prevention
of thromboembolism.

Numerator Patients with AF or atrial flutter for whom an FDA-approved anticoagulant was prescribed* prior to discharge
*Prescribed—also satisfied by documentation in current medication list

Denominator Patients with AF or atrial flutter who do not have a documented CHA2DS2-VASc risk score of 0 or 1, if male, and 0-2, if female.

Denominator Exclusions n Patients age <18 y

n Patients with moderate or severe mitral stenosis
n Patients with a mechanical prosthetic heart valve
n Patients with transient or reversible causes of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery)
n Patients who leave against medical advice
n Patients who die during hospitalization
n Patients who are on comfort care measures only
n Patients who are transferred to another acute care hospital

Denominator Exceptions n Documentation of a medical reason for not prescribing an FDA-approved anticoagulant to a patient with a CHA 2 DS2 -VASc score
of $2 for men and $3 for women, including present or planned left atrial appendage occlusion or ligation
n Documentation of a patient reason for not prescribing an FDA-approved anticoagulant drug for the prevention of
thromboembolism, including patient preference for not receiving anticoagulation
n Documentation of a patient being enrolled in a clinical trial related to AF or atrial flutter

Measurement Period Encounter

Sources of Data Medical record or other database (e.g., administrative, clinical, registry)

Attribution Measure reportable at the facility or physician level

Care Setting Inpatient

Rationale

AF, whether paroxysmal, persistent, or permanent and whether symptomatic or silent, significantly increases the risk of thromboembolic ischemic stroke. AF increases
the risk of stroke 5-fold, and AF in the setting of mitral stenosis increases the risk of stroke 20-fold over that of patients in sinus rhythm.
Thromboembolism occurring with AF is associated with a greater risk of recurrent stroke, more severe disability, and mortality (5). Silent AF is also associated with
ischemic stroke (6–9). The appropriate use of anticoagulant therapy and the control of other risk factors, including hypertension and hypercholesterolemia,
substantially reduce stroke risk.
One meta-analysis has stratified ischemic stroke risk among patients with AF using the following point scoring system (10): AF Investigators; CHA2DS2 (congestive heart
failure, hypertension, age $75 y, diabetes mellitus, prior stroke or TIA or thromboembolism [doubled]), or CHA2DS2-VASc (congestive heart failure, hypertension,
age $75 y [doubled] (11), diabetes mellitus, prior stroke or TIA or thromboembolism [doubled], vascular disease, age 65–74 y, sex category).
Compared with the CHA2DS2 score (12), the CHA2DS2-VASc score for AF has a broader score range (0 to 9) and includes a larger number of risk factors (female sex, 65–74
y of age, and vascular disease) (13,14).
The selection of an anticoagulant agent should be based on shared decision-making that takes into account risk factors, cost, tolerability, patient preference, potential
for drug interactions, and other clinical characteristics, including time in the INR therapeutic range if the patient has been on warfarin, irrespective of whether the AF
pattern is paroxysmal, persistent, or permanent.
Clinical Recommendation(s)
2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (4)
1. For patients with AF and an elevated CHA2 DS 2 -VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. Options
include:
Warfarin (Class 1, Level of Evidence: A) (15–17)
Dabigatran (Class 1, Level of Evidence: B) (18)
Rivaroxaban (Class 1, Level of Evidence: B) (19)
Apixaban (Class 1, Level of Evidence: B) (20), or Edoxaban (Class 1, Level of Evidence: B-R) (21)
MODIFIED: This recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of
CHA2 DS 2 -VASc scores is specified in subsequent recommendations. The LOEs for warfarin, dabigatran, rivaroxaban, and apixaban have not been
updated for greater granularity as per the new LOE system (Section 4.1. in the 2019 AF Guideline (4)). The original text can be found in Section 4.1 of
the 2014 AF guideline (22). Additional information about the comparative effectiveness and bleeding risk of DOACs can be found in Section 4.2.2.2.
2. DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in DOAC-eligible patients with AF (except with moderate or
severe mitral stenosis or a mechanical heart valve) (18–21). (Class 1, Level of Evidence: A)
NEW: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve. When the DOAC trials are considered as a group,
the direct thrombin inhibitor and factor Xa inhibitors were at least noninferior and, in some trials, superior to warfarin for preventing stroke and
systemic embolism and were associated with lower risks of serious bleeding.
3. Among patients treated with warfarin, the INR should be determined at least weekly during initiation of anticoagulant therapy and at least monthly when
anticoagulation (INR in range) is stable (23–25). (Class 1, Level of Evidence: A)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
4. In patients with AF (except with moderate or severe mitral stenosis or a mechanical heart valve), the CHA 2 DS 2 -VASc score is recommended for assessment of
stroke risk (15–17). (Class 1, Level of Evidence: B)
MODIFIED: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve.

Continued on the next page

8 Heidenreich et al. JACC VOL. -, NO. -, 2020
2020 ACC/AHA Atrial Fibrillation Measure Update -, 2020:-–-

APPENDIX A. CONTINUED

SHORT TITLE: PM-2 Continued

Clinical Recommendation(s)
5. For patients with AF who have mechanical heart valves, warfarin is recommended (26–30). (Class 1, Level of Evidence: B)
6. Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or
permanent (31–34). (Class 1, Level of Evidence: B)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
7. In patients with AF, anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative
risks of stroke and bleeding, as well as the patient’s values and preferences. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
8. For patients with atrial flutter, anticoagulant therapy is recommended according to the same risk profile used for AF. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
9. Reevaluation of the need for and choice of anticoagulant therapy at periodic intervals is recommended to reassess stroke and bleeding risks. (Class 1, Level
of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”

All patients with exclusions are removed from the denominator. Patients with exceptions are removed from the denominator only if the numerator is not met.
ACC indicates American College of Cardiology; AF, atrial fibrillation; AHA, American Heart Association; DOAC, direct-acting oral anticoagulant; FDA, U.S. Food and Drug Adminis-
tration; HRS, Heart Rhythm Society; INR, international normalized ratio; LOE, level of evidence; PM, performance measure; and TIA, transient ischemic attack.
JACC VOL. -, NO. -, 2020 Heidenreich et al. 9
-, 2020:-–- 2020 ACC/AHA Atrial Fibrillation Measure Update

APPENDIX A. CONTINUED

SHORT TITLE: PM-3 PT/INR Planned Follow-Up Documented Prior to Discharge for Warfarin Treatment

PM-3: Atrial Fibrillation or Atrial Flutter: PT/INR Planned Follow-Up Documented Prior to Discharge for Warfarin Treatment

Measure Description: Percentage of patients, age $18 y, with AF or atrial flutter who have been prescribed warfarin and who have a PT/INR follow-up scheduled
prior to hospital discharge.

Numerator Patients with AF or atrial flutter for whom warfarin was prescribed prior to discharge and for whom a PT/INR follow-up* is scheduled
*Follow-up is scheduled within 2 w for patients who were newly prescribed warfarin or scheduled within 30 d for patients who were
previously on warfarin. A “yes” or “no” should be documented in the medical record to denote whether follow-up PT/INR was scheduled.

Denominator Patients with AF or atrial flutter who were prescribed warfarin

Denominator Exclusions n Patients age <18 y

n Patients with transient or reversible causes of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery)
n Patients who leave against medical advice
n Patients who die during hospitalization
n Patients who are on comfort care measures only
n Patients who are transferred to another acute care hospital

Denominator Exceptions None

Measurement Period Encounter

Sources of Data Medical record or other database (e.g., administrative, clinical, registry)

Attribution Measure reportable at the facility or physician level

Care Setting Inpatient

Rationale

Frequent monitoring of INR level is essential to guiding warfarin dose adjustment to maintain anticoagulation intensity in the desired target range. More frequent
monitoring may be required during initiation of warfarin therapy or when other drugs that interact with warfarin are started or stopped.
Clinical Recommendation(s)

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (4)
1. For patients with AF and an elevated CHA2 DS 2 -VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. Options
include:
Warfarin (Class 1, Level of Evidence: A) (15–17)
Dabigatran (Class 1, Level of Evidence: B) (18)
Rivaroxaban (Class 1, Level of Evidence: B) (19)
Apixaban (Class 1, Level of Evidence: B) (20), or Edoxaban (Class 1, Level of Evidence: B-R) (21)
MODIFIED: This recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of
CHA2 DS 2 -VASc scores is specified in subsequent recommendations. The LOEs for warfarin, dabigatran, rivaroxaban, and apixaban have not been
updated for greater granularity as per the new LOE system (Section 4.1. in the 2019 AF Guideline (4)). The original text can be found in Section 4.1 of
the 2014 AF guideline (22). Additional information about the comparative effectiveness and bleeding risk of DOACs can be found in Section 4.2.2.2.
2. DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in DOAC-eligible patients with AF (except with moderate or
severe mitral stenosis or a mechanical heart valve) (18–21). (Class 1, Level of Evidence: A)
NEW: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve. When the DOAC trials are considered as a group,
the direct thrombin inhibitor and factor Xa inhibitors were at least noninferior and, in some trials, superior to warfarin for preventing stroke and
systemic embolism and were associated with lower risks of serious bleeding.
3. Among patients treated with warfarin, the INR should be determined at least weekly during initiation of anticoagulant therapy and at least monthly when
anticoagulation (INR in range) is stable (23–25). (Class 1, Level of Evidence: A)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
4. In patients with AF (except with moderate or severe mitral stenosis or a mechanical heart valve), the CHA 2 DS 2 -VASc score is recommended for assessment of
stroke risk (15–17). (Class 1, Level of Evidence: B)
MODIFIED: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve.
5. For patients with AF who have mechanical heart valves, warfarin is recommended (26–30). (Class 1, Level of Evidence: B)
6. Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or
permanent (31–34). (Class 1, Level of Evidence: B)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
7. In patients with AF, anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative
risks of stroke and bleeding, as well as the patient’s values and preferences. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
8. For patients with atrial flutter, anticoagulant therapy is recommended according to the same risk profile used for AF. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
9. Reevaluation of the need for and choice of anticoagulant therapy at periodic intervals is recommended to reassess stroke and bleeding risks. (Class 1, Level
of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”

All patients with exclusions are removed from the denominator. Patients with exceptions are removed from the denominator only if the numerator is not met.
ACC indicates American College of Cardiology; AF, atrial fibrillation; AHA, American Heart Association; DOAC, direct-acting oral anticoagulant; HRS, Heart Rhythm Society; INR,
international normalized ratio; LOE, level of evidence; PM, performance measure; PT, prothrombin time; and TIA, transient ischemic attack.
10 Heidenreich et al. JACC VOL. -, NO. -, 2020
2020 ACC/AHA Atrial Fibrillation Measure Update -, 2020:-–-

APPENDIX A. CONTINUED

SHORT TITLE: PM-4 CHA 2 DS 2 -VASc Risk Score Documented (Outpatient)

PM-4: Atrial Fibrillation or Atrial Flutter: CHA 2 DS 2 -VASc Risk Score Documented (Outpatient)

Measure Description: Percentage of patients, age $18 y, with AF or atrial flutter for whom a CHA2DS2-VASc risk score is documented.

Numerator Patients with AF or atrial flutter for whom a CHA2DS2-VASc risk score is documented

Denominator Patients with AF or atrial flutter

Denominator Exclusions n Patients age <18 y

n Patients with moderate or severe mitral stenosis
n Patients with a mechanical prosthetic heart valve
n Patients with transient or reversible causes of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery)
n Patients who are on comfort care measures only
n Patients with another indication for anticoagulation

Denominator Exceptions n Documentation of a medical reason for not prescribing an FDA-approved anticoagulant to a patient with a CHA2 DS2 -VASc
score of $2 for men and $3 for women, including present or planned left atrial appendage occlusion or ligation, hypertrophic
cardiomyopathy, or other reasons
n Documentation of patient preference for not receiving anticoagulation

Measurement Period Reporting year

Sources of Data Medical record or other database (e.g., administrative, clinical, registry)

Attribution Measure reportable at the facility or provider level

Care Setting Outpatient

Rationale

AF, whether paroxysmal, persistent, or permanent and whether symptomatic or silent, significantly increases the risk of thromboembolic ischemic stroke. AF increases
the risk of stroke 5-fold, and AF in the setting of mitral stenosis increases the risk of stroke 20-fold over that of patients in sinus rhythm.
Thromboembolism occurring with AF is associated with a greater risk of recurrent stroke, more severe disability, and mortality (5). Silent AF is also associated with
ischemic stroke (6–9). The appropriate use of anticoagulant therapy and the control of other risk factors, including hypertension and hypercholesterolemia,
substantially reduce stroke risk.
One meta-analysis has stratified ischemic stroke risk among patients with AF using the following point scoring system (10): AF Investigators; CHA2DS2 (congestive heart
failure, hypertension, age $75 y, diabetes mellitus, prior stroke or TIA or thromboembolism [doubled]), or CHA2DS2-VASc (congestive heart failure, hypertension,
age $75 y [doubled] (11), diabetes mellitus, prior stroke or TIA or thromboembolism [doubled], vascular disease, age 65–74 y, sex category).
When compared with the CHA2DS2 score (12), the CHA2DS2-VASc score for AF has a broader score range (0 to 9) and includes a larger number of risk factors (female sex,
65–74 y of age, and vascular disease) (13,14).
The selection of an anticoagulant agent should be based on shared decision-making that takes into account risk factors, cost, tolerability, patient preference, potential
for drug interactions, and other clinical characteristics, including time in the INR therapeutic range if the patient has been on warfarin, irrespective of whether the AF
pattern is paroxysmal, persistent, or permanent.
Clinical Recommendation(s)
2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (4)
1. For patients with AF and an elevated CHA 2 DS2 -VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. Options
include:
Warfarin (Class 1, Level of Evidence: A) (15–17)
Dabigatran (Class 1, Level of Evidence: B) (18)
Rivaroxaban (Class 1, Level of Evidence: B) (19)
Apixaban (Class 1, Level of Evidence: B) (20), or Edoxaban (Class 1, Level of Evidence: B-R) (21)
MODIFIED: This recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of
CHA2 DS2 -VASc scores is specified in subsequent recommendations. The LOEs for warfarin, dabigatran, rivaroxaban, and apixaban have not been
updated for greater granularity as per the new LOE system (Section 4.1. in the 2019 AF Guideline (4)). The original text can be found in Section 4.1 of
the 2014 AF guideline (22). Additional information about the comparative effectiveness and bleeding risk of DOACs can be found in Section 4.2.2.2.
2. DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in DOAC-eligible patients with AF (except with moderate or
severe mitral stenosis or a mechanical heart valve) (18–21). (Class 1, Level of Evidence: A)
NEW: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve. When the DOAC trials are considered as a group,
the direct thrombin inhibitor and factor Xa inhibitors were at least noninferior and, in some trials, superior to warfarin for preventing stroke and
systemic embolism and were associated with lower risks of serious bleeding.
3. Among patients treated with warfarin, the INR should be determined at least weekly during initiation of anticoagulant therapy and at least monthly when
anticoagulation (INR in range) is stable (23–25). (Class 1, Level of Evidence: A)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
4. In patients with AF (except with moderate or severe mitral stenosis or a mechanical heart valve), the CHA2 DS 2 -VASc score is recommended for assessment of
stroke risk (15–17). (Class 1, Level of Evidence: B)
MODIFIED: Exclusion criteria are now defined as moderate or severe mitral stenosis or a mechanical heart valve.
5. For patients with AF who have mechanical heart valves, warfarin is recommended (26–30). (Class 1, Level of Evidence: B)
6. Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or
permanent (31–34). (Class 1, Level of Evidence: B)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
7. In patients with AF, anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative
risks of stroke and bleeding, as well as the patient’s values and preferences. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”

Continued on the next page

JACC VOL. -, NO. -, 2020 Heidenreich et al. 11
-, 2020:-–- 2020 ACC/AHA Atrial Fibrillation Measure Update

APPENDIX A. CONTINUED

SHORT TITLE: PM-4 Continued

Clinical Recommendation(s)
8. For patients with atrial flutter, anticoagulant therapy is recommended according to the same risk profile used for AF. (Class 1, Level of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”
9. Reevaluation of the need for and choice of anticoagulant therapy at periodic intervals is recommended to reassess stroke and bleeding risks. (Class 1, Level
of Evidence: C)
MODIFIED: “Antithrombotic” was changed to “anticoagulant.”

All patients with exclusions are removed from the denominator. Patients with exceptions are removed from the denominator only if the numerator is not met. Physician performance
measures and related data specifications were developed by the American Medical Association (AMA) convened Physician Consortium for Performance Improvement (PCPI), the
American College of Cardiology (ACC), and the American Heart Association (AHA) to facilitate quality improvement activities by physicians. These performance measures are not clinical
guidelines and do not establish a standard of medical care and have not been tested for all potential applications. While copyrighted, they can be reproduced and distributed, without
modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the
performance measures for commercial gain, or incorporation of the performance measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial
uses of the measures require a license agreement between the user and the AMA (on behalf of the PCPI) or the ACC or the AHA. Neither the AMA, ACC, AHA, the PCPI nor its members
shall be responsible for any use of these measures. THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. ª 2020 American College of
Cardiology, American Heart Association, and American Medical Association. All Rights Reserved. Limited proprietary coding is contained in the measure specifications for convenience.
Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the ACC, the AHA, the PCPI and its members disclaim all liability
for use or accuracy of any Current Procedural Terminology (CPT) or other coding contained in the specifications. CPT contained in the measures specifications is copyright 2020
American Medical Association. LOINC copyright 2004–2020 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT) copyright 2004–2020
International Health Terminology Standards Development Organisation. All Rights Reserved. Use of SNOMED CT is only authorized within the United States.
ACC indicates American College of Cardiology; AF, atrial fibrillation; AHA, American Heart Association; DOAC, direct-acting oral anticoagulant; FDA, U.S. Food and Drug Adminis-
tration; HRS, Heart Rhythm Society; INR, international normalized ratio; LOE, level of evidence; PM, performance measure; and TIA, transient ischemic attack.
12 Heidenreich et al. JACC VOL. -, NO. -, 2020
2020 ACC/AHA Atrial Fibrillation Measure Update -, 2020:-–-

APPENDIX A. CONTINUED

SHORT TITLE: PM-5 Anticoagulation Prescribed (Outpatient)

PM-5: Atrial Fibrillation or Atrial Flutter: Anticoagulation Prescribed (Outpatient)

Measure Description: Percentage of patients, age $18 y, who were prescribed an FDA-approved anticoagulant drug for the prevention of thromboembolism during
the measurement period.

Numerator Patients with AF or atrial flutter for whom an FDA-approved anticoagulant was prescribed*
*Prescribed—also satisfied by documentation in current medication list

Denominator Patients with AF or atrial flutter who do not have a documented CHA2DS2-VASc risk score of 0 or 1, if male, and 0-2, if female.

Denominator Exclusions n Patients age <18 y

n Patients with moderate or severe mitral stenosis
n Patients with a mechanical prosthetic heart valve
n Patients with transient or reversible causes of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery)
n Patients who are on comfort care measures only

Denominator Exceptions n Documentation of a medical reason for not prescribing an FDA-approved anticoagulant drug to a patient with a CHA 2 DS 2 -
VASc score of $2 for men and $3 for women, including present or planned left atrial appendage occlusion or ligation
n Documentation of a patient reason for not prescribing an FDA-approved anticoagulant drug for the prevention of
thromboembolism, including patient preference for not receiving anticoagulation
n Documentation of a patient being enrolled in a clinical trial related to AF or atrial flutter treatment

Measurement Period Reporting year

Sources of Data Medical record or other database (e.g., administrative, clinical, registry)

Attribution Measure reportable at the facility or provider level

Care Setting Outpatient

Rationale

AF, whether paroxysmal, persistent, or permanent and whether symptomatic or silent, significantly increases the risk of thromboembolic ischemic stroke. AF increases
the risk of stroke 5-fold, and AF in the setting of mitral stenosis increases the risk of stroke 20-fold over that of patients in sinus rhythm.
Thromboembolism occurring with AF is associated with a greater risk of recurrent stroke, more severe disability, and mortality (5). Silent AF is also associated with
ischemic stroke (6–9). The appropriate use of anticoagulant therapy and the control of other risk factors, including hypertension and hypercholesterolemia,
substantially reduce stroke risk.
One meta-analysis has stratified ischemic stroke risk among patients with nonvalvular AF using the following point scoring system (10): AF Investigators; CHA2DS2
(congestive heart failure, hypertension, age $75 y, diabetes mellitus, prior stroke or TIA or thromboembolism [doubled]), or CHA2DS2-VASc (congestive heart failure,
hypertension, age $75 y [doubled] (11), diabetes mellitus, prior stroke or TIA or thromboembolism [doubled], vascular disease, age 65–74 y, sex category).
Subsequent work demonstrated that the risk differs for men and women (4).
When compared with the CHA2DS2 score (12), the CHA2DS2-VASc score for nonvalvular AF has a broader score range (0 to 9) and includes a larger number of risk factors
(female sex, 65–74 y of age, and vascular disease) (13,14).
The selection of an anticoagulant agent should be based on shared decision-making that takes into account risk factors, cost, tolerability, patient preference, potential
for drug interactions, and other clinical characteristics, including time in the INR therapeutic range if the patient has been on warfarin, irrespective of whether the AF
pattern is paroxysmal, persistent, or permanent.
The term “nonvalvular AF” was clarified in the 2019 update and does not imply the absence of valvular heart disease. Instead, as used in the 2019 guideline update,
nonvalvular AF is “AF in the absence of moderate or severe mitral stenosis or a mechanical heart valve” (4).
Clinical Recommendation(s)

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (4)
1. For patients with AF and an elevated CHA2 DS 2 -VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. Options
include:
Warfarin (Class 1, Level of Evidence: A) (15–17)
Dabigatran (Class 1, Level of Evidence: B) (18)
Rivaroxaban (Class 1, Level of Evidence: B) (19)
Apixaban (Class 1, Level of Evidence: B) (20), or Edoxaban (Class 1, Level of Evidence: B-R) (21)
MODIFIED: This recommendation has been updated in response to the approval of edoxaban, a new factor Xa inhibitor. More precision in the use of
CHA2 DS2 -VASc scores is specified in subsequent recommendations. The LOEs for warfarin, dabigatran, rivaroxaban, and apixaban have not been
updated for greater granularity as per the new LOE system (Section 4.1. in the 2019 AF Guideline (4)). The original text can be found in Section 4.1 of
the 2014 AF guideline (22). Additional information about the comparative effectiveness and bleeding risk of DOACs can be found in Section 4.2.2.2.

All patients with exclusions are removed from the denominator. Patients with exceptions are removed from the denominator only if the numerator is not met. Physician performance
measures and related data specifications were developed by the American Medical Association (AMA) convened Physician Consortium for Performance Improvement (PCPI), the
American College of Cardiology (ACC), and the American Heart Association (AHA) to facilitate quality improvement activities by physicians. These performance measures are not clinical
guidelines and do not establish a standard of medical care and have not been tested for all potential applications. While copyrighted, they can be reproduced and distributed, without
modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the
performance measures for commercial gain, or incorporation of the performance measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial
uses of the measures require a license agreement between the user and the AMA (on behalf of the PCPI) or the ACC or the AHA. Neither the AMA, ACC, AHA, the PCPI nor its members
shall be responsible for any use of these measures. THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. ª 2020 American College of
Cardiology, American Heart Association, and American Medical Association. All Rights Reserved. Limited proprietary coding is contained in the measure specifications for convenience.
Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the ACC, the AHA, the PCPI and its members disclaim all liability
for use or accuracy of any Current Procedural Terminology (CPT) or other coding contained in the specifications. CPT contained in the measures specifications is copyright 2020
American Medical Association. LOINC copyright 2004–2020 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT) copyright 2004–2020
International Health Terminology Standards Development Organisation. All Rights Reserved. Use of SNOMED CT is only authorized within the United States.
ACC indicates American College of Cardiology; AF, atrial fibrillation; AHA, American Heart Association; DOAC, direct-acting oral anticoagulant; FDA, U.S. Food and Drug Adminis-
tration; HRS, Heart Rhythm Society; INR, international normalized ratio; LOE, level of evidence; PM, performance measure; and TIA, transient ischemic attack.
JACC VOL. -, NO. -, 2020 Heidenreich et al. 13
-, 2020:-–- 2020 ACC/AHA Atrial Fibrillation Measure Update

APPENDIX B. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)—

2020 UPDATE TO THE 2016 ACC/AHA CLINICAL PERFORMANCE AND QUALITY MEASURES FOR
ADULTS WITH ATRIAL FIBRILLATION OR ATRIAL FLUTTER

The Task Force makes every effort to avoid actual, that are pertinent to the document are included in the
potential, or perceived conflicts of interest that could arise appendixes: Appendix B for relevant writing committee
as a result of RWI. Detailed information on the ACC/ RWI and Appendix C for comprehensive peer reviewer
AHA policy on RWI can be found online. All members of RWI. Additionally, to ensure complete transparency, the
the writing committee, as well as those selected to serve as writing committee members’ comprehensive disclosure
peer reviewers of this document, were required to disclose information, including RWI not relevant to the present
all current relationships and those existing within the 12 document, is available online. Disclosure information for
months before the initiation of this writing effort. ACC/ the Task Force is also available online.
AHA policy also requires that the writing committee chair The work of the writing committee was supported
and at least 50% of the writing committee have no rele- exclusively by the ACC and the AHA without commer-
vant RWI. cial support. Members of the writing committee vol-
Any writing committee member who develops new RWI unteered their time for this effort. Meetings of the
during his or her tenure on the writing committee is writing committee were confidential and attended only
required to notify staff in writing. These statements are by writing committee members and staff from the ACC,
reviewed periodically by the Task Force and by members AHA, and the HRS, which served as a collaborator on
of the writing committee. Author and peer reviewer RWI this project.
14 Heidenreich et al. JACC VOL. -, NO. -, 2020
2020 ACC/AHA Atrial Fibrillation Measure Update -, 2020:-–-

APPENDIX B. CONTINUED

Institutional,
Ownership/ Organizational,
Speakers Partnership/ Personal or Other Expert
Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Paul A. Heidenreich Stanford VA Palo Alto Health Care None None None None None None
(Chair) System—Professor of Medicine

N. A. Mark Estes III University of Pittsburgh, n Boston Scientific* None None None n Boston Scientific* None
Department of Medicine— n Medtronic* n Medtronic*
Professor of Medicine n St. Jude Medical* n St. Jude Medical*

Gregg C. Fonarow UCLA Medical Center— n Abbott* None None None n Boston Scientific None
Professor of Medicine n Amgen
n AstraZeneca
n Janssen
Pharmaceuticals
n Medtronic
n Merck
n Novartis*

Corrine Y. Jurgens Boston College, School of None None None None None None
Nursing—Associate Professor

Michelle M. Kittleson Smidt Heart Institute, Cedars None None None None None None
Sinai—Professor of Medicine

Joseph E. Marine Johns Hopkins University— None None None None None None
Associate Professor of Medicine/
Cardiology

David D. McManus University of Massachusetts n Bristol Myers None None n Biotronik* n Bristol Myers None
Medical School—Associate Squibb* n Pfizer* Squibb
Professor n Pfizer* n Philips (Steering
Healthcare* Committee)†

Robert L. McNamara Yale School of Medicine—Associate None None None None None None
Professor of Medicine
(Cardiology), Cardiovascular
Medicine

This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were
reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily
reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of $5% of the voting
stock or share of the business entity, or ownership of $$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of
the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are
modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, in-
tellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in
the document or makes a competing drug or device addressed in the document; or c) the person, or a member of the person’s household, has a reasonable potential for financial,
professional, or other personal gain or loss as a result of the issues/content addressed in the document.
*Significant relationship.
†No financial benefit.
ACC indicates American College of Cardiology; AHA, American Heart Association; HRS, Heart Rhythm Society; RWI, relationships with industry or other entities; UCLA, University of
California, Los Angeles; and VA, Veterans Affairs.
JACC VOL. -, NO. -, 2020 Heidenreich et al. 15
-, 2020:-–- 2020 ACC/AHA Atrial Fibrillation Measure Update

APPENDIX C. REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (COMPREHENSIVE)—

2020 UPDATE TO THE 2016 ACC/AHA CLINICAL PERFORMANCE AND QUALITY MEASURES FOR ADULTS
WITH ATRIAL FIBRILLATION OR ATRIAL FLUTTER

Institutional,
Organizational,
Ownership/ or Other
Peer Speakers Partnership/ Personal Financial Expert
Reviewer Representation Employment Consultant Bureau Principal Research Benefit Witness

Boback Ziaeian Official TFPM UCLA David Geffen n AHA None None n AHA* None None
Lead Reviewer School of Medicine— n NIH*
Assistant Professor;
VA Greater Los
Angeles Healthcare
System—Director of
Telecardiology

Matthew Official ACC Vancouver Coastal n Medtronic of None None n Research n Bayliss None
Bennett Health Research Canada Enrollment Medical†
Institute— Clinical n St. Jude Medical
Assistant Professor

Anabelle S. Official ACC Rush Heart Center None None None None n Apple‡ None
Volgman for Women— n Novartis†
Professor

L. Samuel Wann Official ACC Columbia St. Mary’s None None None None None None
Hospital, Ascension
Healthcare— Clinical
Cardiologist

Carolynn Spera Official AHA New York None None None None None None
Bruno University—Clinical
Associate Professor

James V. Official AHA Yale University n ACC NCDR* None None n Janssen n Biosense None
Freeman School of Medicine— n Biosense Pharmaceuticals Webster†
Associate Professor Webster n NHLBI* n Boston
n Boston Scientific†
Scientific n Sentreheart†
n Medtronic

Pamela J. Official AHA Mayo Clinic Saint None None None None None None
McCabe Mary’s Hospital M-
90—Nurse Scientist

Jonathan P. Official HRS Duke University n Abbott* None None n Abbott* None None
Piccini School of Medicine— n Allergan n AHA*
Associate Professor n ARCA n Association for
of Medicine, biopharma the Advance-
Associate Professor n Biotronik ment of Medical
in Population Health n Medtronic* Instrumentation*
Sciences, Member in n Milestone n Bayer*
the Duke Clinical n MyoKardia* n Boston
Research Institute n Philips* Scientific*
n Sanofi-Aventis* n Gilead Sciences*
n UpToDate* n Philips*

Sana M. Content Duke University n Medtronic None None n Abbott n Abbott n Plaintiff, pa-
Al-Khatib ACC/AHA School of Medicine— n Milestone n FDA* n AHA* tient died of VT
Professor of Pharmaceuticals n Medtronic n Bristol Myers due to
Medicine, Member in n NHLBI* Squibb QT-prolonging
the Duke Clinical n PCORI* n Medtronic meds, 2018
Research Institute n Pfizer n Plaintiff, SCD,
2018
n Plaintiff, SCD
Prevention,
2018
Duy T. Nguyen Content Stanford University— None None n EpyNova None n CardioNXT‡ None
ACC/AHA Clinical Associate Medtech‡
Professor, Medicine
-Cardiovascular
Medicine; Director,
Translational and
Experimental EP
Research
Laboratory; Fellow,
Stanford Faculty
Biodesign

Continued on the next page

16 Heidenreich et al. JACC VOL. -, NO. -, 2020
2020 ACC/AHA Atrial Fibrillation Measure Update -, 2020:-–-

APPENDIX C. CONTINUED

Institutional,
Organizational,
Ownership/ or Other
Peer Speakers Partnership/ Personal Financial Expert
Reviewer Representation Employment Consultant Bureau Principal Research Benefit Witness

Paul D. Varosy Content ACC/ VA Eastern None None None n Research Grant n AHA‡ None
AHA Colorado Health Funding: PI
Care System— Career Develop-
Director of Cardiac ment Award, Co-
Electrophysiology Investigator VA
Merit Review
Grant*

This table represents all relationships of reviewers with industry and other entities that were reported at the time of peer review, including those not deemed to be relevant to this
document, at the time this document was under review. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a
significant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 of the fair market value of the
business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial
benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of
review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories or addi-
tional information about the ACC/AHA Disclosure Policy for Writing Committees.
*Significant relationship.
†This disclosure was entered under the Clinical Trial Enroller category in the ACC’s disclosure system.
‡No financial benefit.
ACC indicates American College of Cardiology; AHA, American Heart Association; EP, electrophysiology; FDA, U.S. Food and Drug Administration; HRS, Heart Rhythm Society; NCDR,
National Cardiovascular Data Registry; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; PCORI, Patient-Centered Outcomes Research Institute; PI,
principal investigator; SCD, sudden cardiac death; TFPM, Task Force on Performance Measures, UCLA, University of California, Los Angeles; VA, Veterans Affairs; and VT, ventricular
tachycardia.