Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Compare Versions of: "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)"
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| Measure Information | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period |
|---|---|---|---|
| Title | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) |
| CMS eCQM ID | CMS135v11 | CMS135v12 | CMS135v13 |
| CBE ID* | 0081e | 0081e | 0081e |
| MIPS Quality ID | 005 | 005 | 005 |
| Measure Steward | American Heart Association | American Heart Association | American Heart Association |
| Description |
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) <=40% who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period |
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) =40% who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period |
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) <=40% who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process |
| Stratification | *See CMS135v11.html |
None |
None |
| Risk Adjustment | *See CMS135v11.html |
None |
None |
| Rationale | *See CMS135v11.html |
Use of ACE inhibitor, ARB, or ARNI therapy has been associated with improved outcomes in patients with reduced LVEF. Long-term therapy with ARBs have also been shown to reduce morbidity and mortality, especially in ACE inhibitor–intolerant patients. More recently, ARNI therapy has also been shown to more significantly improve outcomes, such that the newest guidelines recommend replacement of ACE inhibitors or ARBs with ARNI therapy in eligible patients. However, despite the benefits of these drugs, use of ACE inhibitor, ARB, or ARNI remains suboptimal. |
Use of ACE inhibitor, ARB, or ARNI therapy has been associated with improved outcomes in patients with reduced LVEF. Long-term therapy with ARBs have also been shown to reduce morbidity and mortality, especially in ACE inhibitor–intolerant patients. More recently, ARNI therapy has also been shown to more significantly improve outcomes, such that the newest guidelines recommend replacement of ACE inhibitors or ARBs with ARNI therapy in eligible patients. However, despite the benefits of these drugs, use of ACE inhibitor, ARB, or ARNI remains suboptimal. |
| Clinical Recommendation Statement | *See CMS135v11.html |
In patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and New York Heart Association (NYHA) class II to III symptoms, the use of ARNI is recommended to reduce morbidity and mortality (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2022). In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNI is not feasible (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2022). In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNI is not feasible, the use of ARB is recommended to reduce morbidity and mortality. (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2022). In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality (Class I, Level of Evidence B-R) (ACC/AHA/HFSA, 2022). ARNI should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi (Class II: Harm, Level of Evidence B-R) (ACC/AHA/HFSA, 2022). ARNI should not be administered to patients with any history of angioedema (Class III: Harm, Level of Evidence C-LD) (ACC/AHA/HFSA, 2022). ACEi should not be administered to patients with any history of angioedema (Class III: Harm, Level of Evidence C-LD) (ACC/AHA/HFSA, 2022). Drugs Commonly Used for Stage C HFrEF (abbreviated to align with focus of measure to include only ACE inhibitors, ARB and ARNI therapy) Drug Initial Daily Dose(s) Target Dose(s) Mean Doses Achieved in Clinical Trials ACEi Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg total daily Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg total daily Fosinopril 5 to 10 mg once 40 mg once N/A Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg total daily Perindopril 2 mg once 8 to 16 mg once N/A Quinapril 5 mg twice 20 mg twice N/A Ramipril 1.25 to 2.5 mg once 10 mg once N/A Trandolapril 1 mg once 4 mg once N/A ARB Candesartan 4 to 8 mg once 32 mg once 24 mg total daily Losartan 25 to 50 mg once 50 to 150 mg once 129 mg total daily Valsartan 20 to 40 mg twice 160 mg twice 254 mg total daily ARNI Sacubitril- 49/51 mg twice 97/103 mg twice 182/193 mg valsartan (sacubitril/valsartan) (sacubitril/valsartan) (sacubitril/valsartan) total (therapy may be initiated daily at 24/26 mg twice) |
In patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and New York Heart Association (NYHA) class II to III symptoms, the use of ARNI is recommended to reduce morbidity and mortality (Class I, Level of Evidence A) (Heidenreich et al., 2022). In patients with previous or current symptoms of chronic HFrEF, the use of angiotension-converting enzyme inhibitors (ACEi) is beneficial to reduce morbidity and mortality when the use of ARNI is not feasible (Class I, Level of Evidence A) (Heidenreich et al., 2022). In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNI is not feasible, the use of ARB is recommended to reduce morbidity and mortality. (Class I, Level of Evidence A) (Heidenreich et al., 2022). In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality (Class I, Level of Evidence B-R) (Heidenreich et al., 2022). ARNI should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi (Class II: Harm, Level of Evidence B-R) (Heidenreich et al., 2022). ARNI should not be administered to patients with any history of angioedema (Class III: Harm, Level of Evidence C-LD) (Heidenreich et al., 2022). ACEi should not be administered to patients with any history of angioedema (Class III: Harm, Level of Evidence C-LD) (Heidenreich et al., 2022). Drugs Commonly Used for Stage C HFrEF (abbreviated to align with focus of measure to include only ACE inhibitors, ARB and ARNI therapy) Drug Initial Daily Dose(s) Target Dose(s) Mean Doses Achieved in Clinical Trials ACEi Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg total daily Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg total daily Fosinopril 5 to 10 mg once 40 mg once N/A Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg total daily Perindopril 2 mg once 8 to 16 mg once N/A Quinapril 5 mg twice 20 mg twice N/A Ramipril 1.25 to 2.5 mg once 10 mg once N/A Trandolapril 1 mg once 4 mg once N/A ARB Candesartan 4 to 8 mg once 32 mg once 24 mg total daily Losartan 25 to 50 mg once 50 to 150 mg once 129 mg total daily Valsartan 20 to 40 mg twice 160 mg twice 254 mg total daily ARNI Sacubitril- 49/51 mg twice 97/103 mg twice 182/193 mg valsartan (sacubitril/valsartan) (sacubitril/valsartan) (sacubitril/valsartan) total (therapy may be initiated daily at 24/26 mg twice) |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *See CMS135v11.html |
Prescribed - prescription given to the patient for ACE inhibitor or ARB or ARNI therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB or ARNI therapy as documented in current medication list. LVEF <=40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction (LVSD). The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients. |
Prescribed - prescription given to the patient for ACE inhibitor or ARB or ARNI therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB or ARNI therapy as documented in current medication list. LVEF <=40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction (LVSD). The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients. |
| Guidance |
This eCQM is to be reported as patient-based. To satisfy this measure, it must be reported for all heart failure patients at least once during the measurement period if seen in the outpatient setting. The requirement of two or more visits is used to establish that the eligible professional or eligible clinician has an existing relationship with the patient. A range value should satisfy the logic requirement for 'Ejection Fraction' as long as the ranged observation value clearly meets the less than or equal to 40% threshold noted in the denominator logic. A range that is greater than 40% would not meet the measure requirement. Eligible clinicians who have given a prescription for or whose patient is already taking an Angiotensin-Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) would meet performance for this measure. Other combination therapies that consist of an ACEI plus diuretic, ARB + neprilysin inhibitor (ARNI), ARB plus diuretic, ACEI plus calcium channel blocker, ARB plus calcium channel blocker, or ARB plus calcium channel blocker plus diuretic would also meet performance for this measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This eCQM is to be reported as patient-based. To satisfy this measure, it must be reported for all heart failure patients at least once during the measurement period. The requirement of two or more visits is used to establish that the eligible professional or eligible clinician has an existing relationship with the patient. A range value should satisfy the logic requirement for 'Ejection Fraction' as long as the ranged observation value clearly meets the less than or equal to 40% threshold noted in the denominator logic. A range that is greater than 40% would not meet the measure requirement. In order for the Ejection Fraction result pathway to be recognized as below 40%, the result must be reported as a number with unit of %. A text string of "below 40%" or "ejection fraction between 35 and 40%" will not be recognized through electronic data capture. Although, this criteria can also be met using the Diagnosis pathway if specified as "Moderate or Severe." Eligible clinicians who have given a prescription for or whose patient is already taking an Angiotensin-Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) would meet performance for this measure. Other combination therapies that consist of an ACEI plus diuretic, ARB + neprilysin inhibitor (ARNI), ARB plus diuretic, ACEI plus calcium channel blocker, ARB plus calcium channel blocker, or ARB plus calcium channel blocker plus diuretic would also meet performance for this measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This eCQM is to be reported as patient-based. To satisfy this measure, it must be reported for all heart failure patients at least once during the measurement period. The requirement of two or more visits is used to establish that the eligible clinician has an existing relationship with the patient. A range value should satisfy the logic requirement for 'Ejection Fraction' as long as the ranged observation value clearly meets the less than or equal to 40% threshold noted in the denominator logic. A range that is greater than 40% would not meet the measure requirement. In order for the Ejection Fraction result pathway to be recognized as below 40%, the result must be reported as a number with unit of %. A text string of "below 40%" or "ejection fraction between 35 and 40%" will not be recognized through electronic data capture. Although, this criteria can also be met using the Diagnosis pathway if specified as "Moderate or Severe." Eligible clinicians who have given a prescription for or whose patient is already taking an Angiotensin-Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) would meet performance for this measure. Other combination therapies that consist of an ACEI plus diuretic, ARB + neprilysin inhibitor (ARNI), ARB plus diuretic, ACEI plus calcium channel blocker, ARB plus calcium channel blocker, or ARB plus calcium channel blocker plus diuretic would also meet performance for this measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Initial Population |
All patients aged 18 years and older with two qualifying encounters during the measurement period and a diagnosis of heart failure |
All patients aged 18 years and older with two qualifying encounters during the measurement period and a diagnosis of heart failure |
All patients aged 18 years and older with two qualifying encounters during the measurement period and a diagnosis of heart failure on or before at least one qualifying encounter |
| Denominator |
Equals Initial Population with a current or prior LVEF <= 40% |
Equals Initial Population with a current or prior LVEF <= 40% |
Equals Initial Population with a current or prior LVEF <= 40% |
| Denominator Exclusions |
Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD) prior to the end of the outpatient encounter with Moderate or Severe LVSD |
Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD) prior to the end of the outpatient encounter with Moderate or Severe LVSD |
Patients with a history of heart transplant or with a Left Ventricular Assist Device (LVAD) prior to the end of the outpatient encounter with Moderate or Severe LVSD |
| Numerator |
Patients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period |
Patients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period |
Patients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., pregnancy, renal failure due to ACEI, allergy, intolerance, other medical reasons). Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., patient declined, other patient reasons). |
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., pregnancy, renal failure due to ACEI, allergy, intolerance, other medical reasons). Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., patient declined, other patient reasons). |
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., pregnancy, renal failure due to ACEI, allergy, intolerance, other medical reasons). Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., patient declined, other patient reasons). |
| Telehealth Eligible | Yes | Yes | Yes |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Additional Resources for CMS135v12
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Annual Update
Updated Clinical Recommendation Statement to align with current heart failure guidelines.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section: Definition
Source of Change: Annual Update
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section: Guidance
Source of Change: Annual Update
Added guidance to clarify the options for capturing Ejection Fraction results to meet measure requirements.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
Updated Initial Population logic to ensure two distinct encounters are captured to satisfy the two qualifying encounters requirement and better align with measure intent.
Measure Section: Initial Population
Source of Change: Measure Lead
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Standards/Technical Update
Added 'day of' specificity to definitions to harmonize with other measures and to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Measure Lead
Applied a new shared CQL library, 'HFCommonDefinitions', to reduce duplication of common definitions between heart failure related eCQMs.
Measure Section: Definitions
Source of Change: Measure Lead
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Deleted direct reference code RxNorm code (1656328) based on applicability of value set and/or OID.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.526.3.1489): Renamed to ACE Inhibitor or ARB or ARNI Ingredient based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set Heart Failure (2.16.840.1.113883.3.526.3.376): Added 5 SNOMED CT codes (1204200007, 1204203009, 1204204003, 1204206001, 1204462004) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113762.1.4.1178.56): Renamed to Heart Transplant Complications based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set (2.16.840.1.113762.1.4.1178.58): Renamed to Left Ventricular Assist Device Complications based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Left Ventricular Assist Device Placement (2.16.840.1.113762.1.4.1178.61): Added 1 SNOMED CT code (700151002) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Patient Reason (2.16.840.1.113883.3.526.3.1008): Deleted 3 SNOMED CT codes (183944003, 413310006, 413312003) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Pregnancy (2.16.840.1.113883.3.526.3.378): Added 175 ICD-10-CM codes based on terminology update. Deleted 14 ICD-10-CM codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update