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)"
The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.
Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
Compare version to
| Measure Information | 2022 Performance Period | 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) | 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 | CMS135v10 | CMS135v11 | CMS135v12 | CMS135v13 |
| CBE ID* | 0081e | 0081e | 0081e | 0081e |
| MIPS Quality ID | 005 | 005 | 005 | 005 |
| Measure Steward | American Heart Association-American Stroke Association | 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 ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge |
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 | Proportion measure |
| Measure Type | Process | Process | Process | Process |
| Stratification | *See CMS135v10.html | *See CMS135v11.html |
None |
None |
| Risk Adjustment | *See CMS135v10.html | *See CMS135v11.html |
None |
None |
| Rationale | *See CMS135v10.html | *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 CMS135v10.html | *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 |
Higher score indicates better quality |
| Definition | *See CMS135v10.html | *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 or episode-based, depending on the clinical setting. 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. If the patient has an eligible inpatient discharge during the measurement period, as defined in the measure logic, it is expected to be reported at each hospital discharge. The requirement of two or more visits used in Population Criteria 1 is 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 40% threshold noted in the denominator logic. A range that is inclusive of or 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 5.5. Please refer to the eCQI resource center 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 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 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 |
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% |
Equals Initial Population with a current or prior LVEF <= 40% |
| Denominator Exclusions |
None |
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 ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge |
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 |
Not Applicable |
| Denominator Exceptions |
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, 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 system reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., other system 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). |
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 | Yes |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS135v10
Header
Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
Updated Measure Steward.
Measure Section: Measure Steward
Source of Change: Measure Lead
Updated Measure Developer.
Measure Section: Measure Developer
Source of Change: Measure Lead
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Annual Update
Added ARNI medications to the medication dosing table to align with guidelines and specification.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
Updated definition pertaining to Moderate to Severe LVSD to better align with logic.
Measure Section: Definition
Source of Change: Annual Update
Logic
Updated the Heart Failure Outpatient Encounter with Moderate or Severe LVSD and Heart Failure Inpatient Encounter with Moderate or Severe LVSD denominator definitions' timing from 'before' to 'starts before' to align timing with intent.
Measure Section: Denominator
Source of Change: Annual Update
Removed 'Medication, Active' from Population 2 numerator definition to align with standard capture of discharge medications.
Measure Section: Numerator
Source of Change: Annual Update
Added timing element to Pregnancy Diagnosis definition to prevent previous pregnancies from being captured in the measure.
Measure Section: Denominator Exceptions
Source of Change: Annual Update
Updated Outpatient Encounter definitions and removed FaceToFaceEncounter language to signal broadening of encounter type.
Measure Section: Definitions
Source of Change: Annual Update
Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.
Measure Section: Multiple Sections
Source of Change: Standards Update
Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.
Measure Section: Multiple Sections
Source of Change: Standards Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Value set ACE Inhibitor or ARB or ARNI (2.16.840.1.113883.3.526.3.1139): Deleted 9 RxNorm codes (199622, 199707, 199708, 199709, 199816, 199817, 411434, 858921, 199937) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Heart Failure (2.16.840.1.113883.3.526.3.376): Added 1 SNOMED CT code (871617000) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Pregnancy (2.16.840.1.113883.3.526.3.378): Added 77 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Deleted 19 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Deleted 24 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Left Ventricular Systolic Dysfunction (2.16.840.1.113883.3.526.2.859) with direct reference code SNOMED CT code (134401001) based on applicability of a single code to represent clinical data.
Measure Section: Terminology
Source of Change: Annual Update