eMeasure Title

Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

eMeasure Identifier (Measure Authoring Tool) 135 eMeasure Version number 6.0.000
NQF Number 0081 GUID 430ffc53-4122-4421-88cc-2edd8117bb3c
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward PCPI(R) Foundation (PCPI[R])
Measure Developer American Medical Association (AMA)
Measure Developer PCPI(R) Foundation (PCPI[R])
Endorsed By National Quality Forum
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 therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Copyright 2017 American College of Cardiology, American Heart Association and American Medical Association. All Rights Reserved.
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CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) is copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2016 World Health Organization. All Rights Reserved.

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Measure Scoring Proportion
Measure Type Process
Risk Adjustment
Rate Aggregation
In the absence of contraindications, ACE inhibitors or ARBs are recommended for all patients with symptoms of heart failure and reduced left ventricular systolic function. ACE inhibitors remain the first choice for inhibition of the renin-angiotensin system in chronic heart failure, but ARBs can now be considered a reasonable alternative. Both pharmacologic agents have been shown to decrease the risk of death and hospitalization. Additional benefits of ACE inhibitors include the alleviation of symptoms and the improvement of clinical status and overall sense of well-being of patients with heart failure.
Clinical Recommendation Statement
ACE inhibitors are recommended in patients with HFrEF [heart failure with reduced ejection fraction] and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality. (Class I, Level of Evidence: A) (ACCF/AHA, 2013)

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 and ARB therapy)
Drug                       Initial Daily Dose(s)                           Maximum Doses(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

ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACE inhibitor intolerant, unless contraindicated, to reduce morbidity and mortality. (Class I, Level of Evidence: A)  (ACCF/AHA, 2013)

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)

For the hospitalized patient:
In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic
maintenance treatment with GDMT[guideline-directed medical therapy; GDMT represents optimal medical therapy as defined by ACCF/AHA guideline-recommended therapies (primarily Class I)], it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications. (Class I, Level of Evidence: B)  (ACCF/AHA, 2013)
Improvement Notation
Higher score indicates better quality
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 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. J Am Coll Cardiol 2013;62:e147-239. 
Prescribed-Outpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in current medication list.

Prescribed-Inpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at discharge OR ACE inhibitor or ARB therapy to be continued after discharge as documented in the discharge medication list.

LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction.
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 "Count >=2 Encounter, Performed" 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.
Transmission Format
Initial Population
All patients aged 18 years and older with a diagnosis of heart failure
Equals Initial Population with a current or prior LVEF < 40%
Denominator Exclusions
Patients who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Numerator Exclusions
Not Applicable
Denominator Exceptions
Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, 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 therapy (eg, patient declined, other patient reasons).

Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons).
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents

Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables

Measure Set