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Measure: CMS135

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)

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 or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

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

Patient Group Definitions

Group Description Instructions Links
Initial PopulationAll patients aged 18 years and older with a diagnosis of heart failureWebchart Instructions
DenominatorEquals Initial Population with a current or prior LVEF < 40%Webchart Instructions
Denominator ExclusionsNone
NumeratorPatients 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 dischargeWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsDocumentation 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).Webchart Instructions

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS135v10 2022 10.1.000 0081e 430ffc53-4122-4421-88cc-2edd8117bb3c
Steward Developer Endorsed By
American Medical Association (AMA) American Heart Association-American Stroke Association National Quality Forum
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation

This measure is intended to have one reporting rate, which aggregates the following populations into a single performance rate for reporting purposes: 
- Population 1: Patients who were prescribed ACE inhibitor or ARB or ARNI therapy within a 12-month period when seen in the outpatient setting 
- Population 2: Patients who were prescribed ACE inhibitor or ARB or ARNI therapy at each hospital discharge

For the purposes of this measure, a single performance rate can be calculated as follows:
Performance Rate = (Numerator 1 + Numerator 2)/ [(Denominator 1 - Denominator Exceptions 1) + (Denominator 2 - Denominator Exceptions 2)]

Improvement Notation

Higher score indicates better quality

Rationale

In the absence of contraindications, ACE inhibitors, ARB, or ARNI therapy is recommended for all patients with symptoms of heart failure and reduced left ventricular systolic function. Recent trial data have shown ARNI to be superior to ACE inhibitor or ARB therapy, however an ACE inhibitor or ARB should still be used for patients in which an ARNI is contraindicated. Given that ARNI is a newer therapy, uptake has been slow despite updated guideline recommendations that support its use. All pharmacologic agents included in this measure have been shown to decrease the risk of death and hospitalization for patients with heart failure.

Clinical Recommendation Statement

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 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).

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 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. Prescribed-Inpatient setting: prescription given to the patient for ACE inhibitor or ARB or ARNI therapy at discharge OR ACE inhibitor or ARB or ARNI 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 (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.

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Allergy/Intolerance ACE Inhibitor or ARB Ingredient 2.16.840.1.113883.3.526.3.1489
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 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 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, Not Ordered 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
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

CITATIONYancy, 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
CITATIONYancy, 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

Disclaimer

The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measure require a license agreement between the user and the American College of Cardiology (ACC) or the American Heart Association (AHA). Neither the ACC, nor AHA, nor their members shall be responsible for any use of the Measure. ACC and AHA encourage use of the Measure by other health care professionals, where appropriate. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The ACC and AHA and their members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) is copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2020 World Health Organization. All Rights Reserved. The American Medical Association’s and the PCPI(R) Foundation’s significant past efforts and contributions to the performance measure are gratefully acknowledged. Due to technical limitations, registered trademarks are indicated by (R) or [R].

Copyright

Copyright 2021 American College of Cardiology and American Heart Association. All Rights Reserved.

Source: https://ecqi.healthit.gov/ecqm/measures/cmsv1