Measure: CMS135
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Measure Versions
eMeasure Code |
Measure Year |
Full Version Number |
Title |
CMS135v12 |
2024 |
12.1.000 |
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) |
CMS135v11 |
2023 |
11 |
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) |
CMS135v10 |
2022 |
10.1.000 |
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) |
CMS135v9 |
2021 |
9.2.000 |
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) |
CMS135v8 |
2020 |
8.2.000 |
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) |
CMS135v7 |
2019 |
7.1.000 |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) |
CMS135v6 |
2018 |
6.0.000 |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) |
CMS135v5 |
2017 |
5.2.000 |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) |
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 therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Guidance
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 of Encounter, Performed" is to establish that the eligible professional has an existing relationship with the patient.
Patient Group Definitions
Group |
Description |
Instructions Links |
Initial Population | All patients aged 18 years and older with a diagnosis of heart failure | Webchart Instructions |
Denominator | Equals Initial Population with a current or prior LVEF < 40% | Webchart Instructions |
Denominator Exclusions | None | |
Numerator | 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 | Webchart Instructions |
Numerator Exclusions | Not Applicable | Webchart Instructions |
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) | Webchart Instructions |
Details
Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
CMS135v5 |
135 |
2017 |
5.2.000 |
2907 |
430ffc53-4122-4421-88cc-2edd8117bb3c |
Steward |
Developer |
Endorsed By |
American Medical Association (AMA) |
PCPI(R) Foundation (PCPI[R]) |
National Quality Forum |
Scoring Method |
Measure Type |
Stratification |
Risk Adjustment |
Proportion |
PROCESS |
None |
None |
Rate Aggregation
None
Improvement Notation
Higher score indicates better quality
Rationale
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)
Definition
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.
Transmission Format
TBD
Applicable Value Sets
Category |
Value Set |
OID |
Communication: From Patient to Provider |
Patient Reason for ACE Inhibitor or ARB Decline |
2.16.840.1.113883.3.526.3.1140 |
Diagnosis |
Allergy to ACE Inhibitor or ARB |
2.16.840.1.113883.3.526.3.1211 |
Diagnosis |
Heart Failure |
2.16.840.1.113883.3.526.3.376 |
Diagnosis |
Intolerance to ACE Inhibitor or ARB |
2.16.840.1.113883.3.526.3.1212 |
Diagnosis |
Moderate or Severe |
2.16.840.1.113883.3.526.3.1092 |
Diagnosis |
Moderate or Severe LVSD |
2.16.840.1.113883.3.526.3.1090 |
Diagnosis |
Pregnancy |
2.16.840.1.113883.3.526.3.378 |
Diagnosis |
Renal Failure Due to ACE Inhibitor |
2.16.840.1.113883.3.526.3.1151 |
Diagnostic Study, Performed |
Ejection Fraction |
2.16.840.1.113883.3.526.3.1134 |
Encounter, Performed |
Care Services in Long-Term Residential Facility |
2.16.840.1.113883.3.464.1003.101.12.1014 |
Encounter, Performed |
Discharge Services - Hospital Inpatient |
2.16.840.1.113883.3.464.1003.101.12.1007 |
Encounter, Performed |
Face-to-Face Interaction |
2.16.840.1.113883.3.464.1003.101.12.1048 |
Encounter, Performed |
Home Healthcare Services |
2.16.840.1.113883.3.464.1003.101.12.1016 |
Encounter, Performed |
Nursing Facility Visit |
2.16.840.1.113883.3.464.1003.101.12.1012 |
Encounter, Performed |
Office Visit |
2.16.840.1.113883.3.464.1003.101.12.1001 |
Encounter, Performed |
Outpatient Consultation |
2.16.840.1.113883.3.464.1003.101.12.1008 |
Encounter, Performed |
Patient Provider Interaction |
2.16.840.1.113883.3.526.3.1012 |
Medication, Active |
ACE Inhibitor or ARB |
2.16.840.1.113883.3.526.3.1139 |
Medication, Allergy |
ACE Inhibitor or ARB Ingredient |
2.16.840.1.113883.3.526.3.1489 |
Medication, Intolerance |
ACE Inhibitor or ARB |
2.16.840.1.113883.3.526.3.1139 |
Medication, Order |
ACE Inhibitor or ARB |
2.16.840.1.113883.3.526.3.1139 |
Medication, Order |
Medical Reason |
2.16.840.1.113883.3.526.3.1007 |
Medication, Order |
Patient Reason |
2.16.840.1.113883.3.526.3.1008 |
Medication, Order |
System Reason |
2.16.840.1.113883.3.526.3.1009 |
Patient Characteristic Ethnicity |
Ethnicity |
2.16.840.1.114222.4.11.837 |
Patient Characteristic Payer |
Payer |
2.16.840.1.114222.4.11.3591 |
Patient Characteristic Race |
Race |
2.16.840.1.114222.4.11.836 |
Patient Characteristic Sex |
ONC Administrative Sex |
2.16.840.1.113762.1.4.1 |
References
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.
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Copyright
Copyright 2015 American College of Cardiology, American Heart Association and American Medical Association. All Rights Reserved.
Source:
https://ecqi.healthit.gov/ecqm/measures/cms135v5