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 |
| CMS135v13 |
2025 |
13.4.000 |
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) |
| 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 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 or ARNI 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 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 |
| CMS135v9 |
135 |
2021 |
9.2.000 |
0081e |
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
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 and ARB 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
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.
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 |
Left Ventricular Systolic Dysfunction |
2.16.840.1.113883.3.526.3.1091 |
| 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
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
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
Disclaimer
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Copyright 2020 American College of Cardiology, American Heart Association and American Medical Association. All Rights Reserved.
Source:
https://ecqi.healthit.gov/ecqm/measures/cms135v9