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)

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

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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.

The clinical strategy of inhibition of the renin angiotensin system with ACE inhibitors (Class 1, Level of Evidence: A), OR ARBs (Class 1, Level of Evidence: A), OR ARNI (Class 1, Level of Evidence: B-R) in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic heart failure with reduced ejection fraction (HFrEF) to reduce morbidity and mortality (ACC/AHA/HFSA, 2017).

The use of ACE inhibitors is beneficial for patients with prior or current symptoms of chronic HFrEF to reduce morbidity and mortality (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2017).

Treatment with an ACE inhibitor should be initiated at low doses [see excerpt from guideline table below], followed by gradual dose increments if lower doses have been well tolerated... Clinicians should attempt to use doses that have been shown to reduce the risk of cardiovascular events in clinical trials. If these target doses of an ACE inhibitor cannot be used or are poorly tolerated, intermediate doses should be used with the expectation that there are likely to be only small differences in efficacy between low and high doses. Abrupt withdrawal of treatment with an ACE inhibitor can lead to clinical deterioration and should be avoided (ACCF/AHA, 2013).

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)                           Maximum Dose(s)       Mean Doses Achieved in 
                                                                                                                        Clinical Trials
ACE Inhibitors
   Captopril              6.25 mg 3 times                               50 mg 3 times              122.7 mg/d
   Enalapril               2.5 mg twice                                    10 to 20 mg twice        16.6 mg/d
   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/d  
   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
Angiotensin Receptor Blockers
   Candesartan         4 to 8 mg once                                32 mg once                  24 mg/d
   Losartan               25 to 50 mg once                             50 to 150 mg once      129 mg/d
   Valsartan              20 to 40 mg twice                           160 mg twice                 254 mg/d
ARNI
   Sacubitril/             49/51 mg twice (sacubitril                97/103 mg twice          375 mg/d; target dose:
   valsartan              valsartan) (therapy may be              (sacubitril/                    24/26 mg, 49/51 mg OR
                                initiated at 24/26 mg twice)              valsartan)                    97/103 mg twice

The use of ARBs to reduce morbidity and mortality is recommended in patients with current or prior symptoms of chronic HFrEF who are intolerant to ACE inhibitors because of cough or angioedema (Class I, Level of Evidence A) (ACC/AHA/HFSA, 2017).

ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with HFrEF, especially for patients already taking ARBs for other indications, unless contraindicated (Class IIa, Level of Evidence: A) (ACCF/AHA, 2013).

Addition of an ARB may be considered in persistently symptomatic patients with HFrEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated (Class IIb, Level of Evidence: A) (ACCF/AHA, 2013).

The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors (Level of Evidence A), or ARBs (Level of Evidence A) or ARNI (Level of Evidence B-R) in conjunction with evidence-based beta-blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic HFrEF to reduce morbidity and mortality (Class I) (ACC/AHA/HFSA, 2017).

In patients with chronic symptomatic HFrEF New York Heart Association (NYHA) class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality (Class I, Level of Evidence: B-R) (ACC/AHA/HFSA, 2017).

ARNI should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor (Class III, Level of Evidence B-R) (ACC/AHA/HFSA, 2017).

ARNI should not be administered to patients with a history of angioedema (Class III Recommendation, Level of Evidence C-EO) (ACC/AHA/HFSA, 2017).

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., … Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128(16), e240–e327. doi: https://doi.org/10.1161/CIR.0b013e31829e8776'

Reference Type: CITATION

Reference Text: 'Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., … Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation,136(6), e137–e161. doi: 10.1161/cir.0000000000000509'

Prescribed-Outpatient setting: 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.

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 eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All patients aged 18 years and older with two qualifying encounters during the measurement period and a diagnosis of heart failure

Equals Initial Population with a current or prior LVEF <= 40%

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 who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period

Not Applicable

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).

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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