In validating the patients included in the OP-40 STEMI measure, we've come across situations that create questions r/t the measure logic.  I have 3 examples that result in patients being included in Denominator population but they appropriately did not receive thrombolytics or reperfusion.  

1. Female patient that presented to the ER in new onset acute heart failure; her main complaint was fatigue and increasing shortness of breath for the last 3 days.  Her STEMI diagnosis was noted by the cardiologist to be a subacute inferior MI that occurred several days before she presented. In this instance, she was not a candidate for thrombolytics or primary PCI.  She was admitted to the ICU and placed on Dobutamine overnight with plans for a cath and possible PCI the next day.  Regarding the measure, it is noted in the Clinical Recommendation Statement for the measure, the guidelines note that thrombolytics and PCI are recommended for STEMIs that present within 12 hours of onset but there is not a variable to identify the onset in the measure.
2. Male patient that presented with an inferior wall STEMI.  He proceeded to the cath lab for a primary PCI but it is noted as "a failed attempt at PTCA of right coronary artery".  The vessel was noted as highly tortuous.  The cardiologist was able to weave the wire near the lesion but was unable to cross it.  The procedure was aborted and the provider elected to treat this medically after other diagnostic testing.  Regarding the measure, a failed PCI attempt will not have a perfusion date/time.  If, due to the patient's physically anatomy, the PCI failed, there is not a variable to identify this in the measure.
3. Young male with history of "inflammatory chest pain" per patient.  Positive EKG changes and very minimal bump in the Troponin.  STEMI per presentation and taken to the cath lab.  Cath revealed that the patient does not have any coronary artery disease.  The diagnosis noted on the record is Myocardial Infarction with NonObstructive Coronary Arteries.  Regarding the measure, there is no thrombolytic administration or PCI perfusion date/time as there was no intervention.  This patient is now on the appropriate medication regimen but still falls into the denominator population, even though the procedure and thrombolytic are not indicated.
4. Female patient s/p STEMI with hospital discharge one week before presenting to the ER with atypical chest pain.  Evaluation noted Q waves on her EKG.  Initial STEMI procedure was unable to reach a distal spot in one vessel and that was felt to be the source of her pain on return to the ER.  After aspirin and Nitro were administered in the ambulance, her pain resolved.  No pain after arrival, atypical presentation than original STEMI, no EKG changes.  Cardiologist and an external cardiologist reviewed her case and elected to monitor serial troponins and ekgs.  No changes and the patient was discharged in 24 hours.  Her principal diagnosis is Other Chest Pain but because of AHA Coding Guidelines, the secondary diagnosis of STEMI was included as an additional diagnosis and that is what is pulling the patient to this measure.  Her readmission was a 30 day readmission following her initial STEMI but this readmission was not for treatment of a STEMI. Regarding the measure, STEMI as a secondary diagnosis that is present on admit is not addressed in the measure logic.  In this case, the physicians agreed that her pain was atypical chest pain due to the spot that they were unable to reach in the index event.  
5. We have a Free Standing Emergency Department under our CCN and facility.  It is located about 20 minutes away even in times of low traffic.  We get patients in transfer from this facility and the patients have the same encounter number from presentation to the FED through discharge at the main facility.  Regarding the measure logic, there is not a variable to address patients that transfer from a different brick and mortar building.