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.

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)

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'Heidenreich, P.A., Bozkurt, B, Aguilar, D., ... Allen, L. A. (2022). 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895-e1032. doi: 10.1161/CIR.0000000000001063'

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.

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 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 on or before at least one qualifying encounter

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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