2020 ACC - AHA Clinical Performance and Quality Measures HF

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 76, NO.
21, 2020
ª2020 AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION AND AMERICAN HEART
ASSOCIATION, INC. PUBLISHED BY ELSEVIER. ALL RIGHTS RESERVED
PUBLISHED BY ELSEVIER
PERFORMANCE MEASURES
2020 ACC/AHA Clinical Performance

and Quality Measures for Adults With
Heart Failure
A Report of the American College of Cardiology/American Heart Association Task Force on
Performance Measures
Developed in Collaboration With the Heart Failure Society of America

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation,
American Society of Health-System Pharmacists, Heart Rhythm Society, and
the International Society for Heart and Lung Transplantation
Writing Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair Kenneth G. Taylor, MD, FACC, FHFSAy
Committee Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, Vice Chair* Jennifer T. Thibodeau, MD, MSCS, FACC, FHFSA
Members Clyde W. Yancy, MD, MSC, MACC, FAHA, FHFSA

Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA Boback Ziaeian, MD, PHD, FACC, FAHA
Corrine Y. Jurgens, PHD, RN, ANP, FAHA, FHFSA
Barbara A. Pisani, DO, FACC, FAHA
*ACC/AHA Task Force on Performance Measure Liaison.
Bunny J. Pozehl, PHD, APRN-NP, FAHA, FHFSA
John A. Spertus, MD, MPH, FACC, FAHA yHeart Failure Society of America Representative.
This Physician Performance Measurement Set (PPMS) and related data speci fications were developed by the Physician Consortium for Performance Improvement (the
Consortium), including the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical Association (AMA), to facilitate
quality-improvement activities by physicians. The performance measures contained in this PPMS are not clinical guidelines, do not establish a standard of medical care, and
have not been tested for all potential applications. Although copyrighted, they can be reproduced and distributed, without modification, for noncommercial purposes, for
example, use by health care providers in connection with their practices. Commercial use is de fined as the sale, license, or distribution of the performance measures for
commercial gain, or incorporation of the performance measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the PPMS
require a license agreement between the user and the AMA (on behalf of the Consortium) or the ACC or the AHA. Neither the AMA, ACC, AHA, the Consortium, nor its
members shall be responsible for any use of this PPMS.
The measures 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 the code sets. The AMA, the ACC, the AHA, the National Committee for Quality Assurance (NCQA), and the Physician Consortium for Performance Improvement (PCPI)
and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT) or other coding contained in the specifications.
CPT contained in the measures specifications is copyright 2004–2012 American Medical Association. LOINC copyright 2004–2012 Regenstrief Institute, Inc. This material
contains SNOMED CLINICAL TERMS (SNOMED CT) copyright 2004–2012 International Health Terminology Standards Development Organization. All rights reserved.
This document underwent a 14-day peer review between February 7, 2020, and February 21, 2020, and a 30-day public comment period between, February 7, 2020, and
March 8, 2020.
This document was approved by the American College of Cardiology Clinical Policy Approval Committee on June 29, 2020; by the American Heart Association Science
Advisory and Coordinating Committee on June 11, 2020; the American Heart Association Executive Committee on July 22, 2020; and by the Heart Failure Society of America
on July 23, 2020.
The American College of Cardiology requests that this document be cited as follows: Heidenreich PA, Fonarow GC, Breathett K, Jurgens CY, Pisani BA, Pozehl BJ, Spertus
JA, Taylor KG, Thibodeau JT, Yancy CW, Ziaeian B. 2020 ACC/AHA clinical performance and quality measures for adults with heart failure: a report of the American College
of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol 2020;76:2527–64.
This article has been copublished in Circulation: Cardiovascular Quality and Outcomes.
Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.
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ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2020.07.023
2528 Heidenreich et al. JACC VOL. 76, NO. 21, 2020
2020 ACC/AHA HF Measures NOVEMBER 24, 2020:25 27-64
ACC/AHA Task P. Michael Ho, MD, PhD, FACC, FAHA Chairz Leo Lopez, MD, FACC, FAHAz
Force on Jeffrey W. Olin, DO, FACC, FAHAx

Performance H. Vernon Anderson, MD, FACCz Manesh R. Patel, MD, FACCx
Measures Ankeet S. Bhatt, MD, MBAz Faisal Rahman, BM BChz
Biykem Bozkurt, MD, PhD, FACC, FAHA, FHFSAx Matthew Roe, MD, FACCzk
Sandeep Das, MD, MPH, FACCx Katherine B. Salciccioli, MDx
Joao F. Monteiro Ferreira, MD, PhD, FACCz Alex Sandhu, MD, MSzk
Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, Randal J. Thomas, MD, MS, FACC, FAHAzk
Ex Officio Siqin Kye Ye, MD, MSzk
x
Stacy Garcia, RT(R), RN, BSN, MBA-HCMz Boback Ziaeian, MD, PhD, FACC, FAHAz
Michael E. Hall, MD, MS, FACC, FAHAx
Hani Jneid, MD, FACC, FAHAx zAmerican College of Cardiology Representative.
Patricia A. Keegan, DNP, APRN, NP-C xAmerican Heart Association Representative.
zk
kFormer Task Force member; current member during the writing
Christopher Lee, PhD, RN, FAHA, FHFSAx effort.
Short Title: PM-1: Left

Ventricular Ejection
Fraction Assessment
(Outpatient Setting) . . .
2539
Short Title: PM-2: Symptom
TABLE OF CONTENTS and Activity
Assessment (Outpatient
Setting) . . . . . . . . . 2540
TOP 10 TAKE-HOME MESSAGES . . . . . . . . . . . . . . . . . 2529
PREAMBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2529
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2530
1.1. Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . 2533
1.2. Disclosure of Relationships With Industry and

Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2533
2. METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2533
2.1. Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . 2533
2.2. Definition and Selection of Measures . . . . . . . . . 2534
3. ACC/AHA HEART FAILURE MEASURE SET . . . . . . 2534
3.1. Discussion of Changes to 2011 Heart Failure

Measure Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2534
3.1.1. Retired Measures . . . . . . . . . . . . . . . . . . . . 2534

3.1.2. Revised Measures . . . . . . . . . . . . . . . . . . . . 2534
3.1.3. New Measures . . . . . . . . . . . . . . . . . . . . . . . 2534
4. AREAS FOR FURTHER RESEARCH . . . . . . . . . . . . . 2535
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2535
APPENDIX A
Heart Failure Measure Set . . . . . . . . . . . . . . . . . . . . . . 2539

Performance Measures for Heart Failure . . . . . . 2539
Short Title: PM-3: Symptom Management (Outpatient Setting) . . . . . . . . . . . . . . . . . . . .
2541 Short Title: PM-4: Beta-Blocker Therapy for Heart Failure With Reduced Ejection
Fraction (Outpatient and Inpatient Setting) . . . . . . . . . 2542 Short Title: PM-5:
Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker or
Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced
Ejection Fraction (Outpatient and Inpatient Setting) . . . . . . . . . . . . . . . . . . . . . . 2543
Short Title: PM-6: Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure
With Reduced Ejection Fraction (Outpatient and Inpatient Setting) . . . . . . . . . . . . . . . . . .
. . . 2544 Short Title: PM-7: Dose of Beta-Blocker Therapy for Heart Failure With
Reduced Ejection Fraction (Outpatient Setting) . . . . . . . . . . . . . . . . . . . . 2545 Short Title:
PM-8: Dose of Angiotensin-Converting Enzyme Inhibitor, Angiotensin Receptor
Blocker, or Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With
Reduced Ejection Fraction
(Outpatient Setting) . . . . . . . . . . . . . . . . . . . . 2547 Short Title: PM-9: Mineralocorticoid

Receptor Antagonist Therapy for Heart Failure With Reduced Ejection Fraction
(Outpatient and Inpatient Setting) . . . . . . . . 2548 Short Title: PM-10: Laboratory
Monitoring in New Mineralocorticoid Receptor Antagonist Therapy (Outpatient and
Inpatient Setting) . 2549 Short Title: PM-11: Hydralazine/Isosorbide Dinitrate Therapy
for Heart Failure With Reduced Ejection Fraction in Those Self-Identified as Black or
African American (Outpatient and Inpatient Setting) . . . . . . . . . 2550 Short Title: PM-12:
Counseling Regarding Implantable Cardioverter-Defibrillator Implantation for Patients
With Heart
JACC VOL. 76, NO. 21, 2020 Heidenreich et al. 2529
NOVEMBER 24, 2020:2527-6 4 2020 ACC/AHA HF Measures
Failure With Reduced Ejection Fraction on (mineralocorticoid receptor antagonists in patients with heart failure
Guideline-Directed Medical Therapy with reduced left ventricular ejec-tion fraction).
(Outpatient Setting) . . . . . . . . . . . . . . . . . . . . 2551
Short Title: PM-13: Cardiac Resynchronization
5. Other additions to the performance measures include the new medication
Therapy Implantation for Patients With Heart
Failure With Reduced Ejection Fraction on sacubitril/valsartan and use of cardiac resynchronization therapy.
Guideline-Directed Medical Therapy 6. To address frequent lack of titration of heart failure medications, 2 new
(Outpatient Setting) . . . . . . . . . . . . . . . . . . . . 2552 performance measures are included based on dose, either reaching 50% of the
Quality Measures for Heart Failure . . . . . . . . . . . 2553 recommended dose (e.g., beta blocker or angiotensin-converting enzyme
Short Title: QM-1: Patient Self-Care Education inhibitor/angiotensin receptor antagonist/angiotensin receptor neprilysin inhibitor) or
(Outpatient Setting) . . . . . . . . . . . . . . . . . . . . 2553 Short documenting that such a dose was not tolerated or otherwise inappropriate.
Title: QM-2: Measurement of Patient-Reported
Outcome-Health Status
(Outpatient Setting) . . . . . . . . . . . . . . . . . . . . 2554
7. For all measures, if the clinician determines the care is inappropriate for the
Short Title: QM-3: Sustained or Improved
Health Status in Heart Failure (Outcome) patient, that patient is excluded from the measure.
Short Title: QM-4: Postdischarge Appointment
for Patients With Heart Failure 8. For all measures, patients who decline treatment or care are excluded.
(Inpatient Setting) . . . . . . . . . . . . . . . . . . . . . 2556 9. A patient-centered discussion of the benefits and risks of implantable
Structural Measure for Heart Failure . . . . . . . . . 2557 cardioverter-defibrillator treatment remains a performance measure.
Short Title: SM-1: Heart Failure Registry
Participation . . . . . . . . . . . . . . . . . . . . . . . . . . 2557
10. To reflect the increasing importance of patient-reported outcome measures, 2
Rehabilitation Performance Measures Related to Heart Failure patient-reported outcomes quality measures were added that use heart failure patient-
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2558
re-ported outcomes questionnaires currently accepted by the U.S. Food and Drug
Short Title: PM-2: Exercise Training Referral for
Administration.
HFrEF From Inpatient Setting . . . . . . . . . . . . 2558
Short Title: PM-4: Exercise Training Referral for
HFrEF From Outpatient Setting . . . . . . . . . . . 2559
PREAMBLE
APPENDIX B
The American College of Cardiology (ACC)/American Heart
Author Relationships With Industry and
Association (AHA) performance measurement sets serve as vehicles to
Other Entities (Relevant) . . . . . . . . . . . . . . . . . . . . . . . 2560
accelerate translation of scientific evidence into clinical practice. Measure
sets developed by the ACC/AHA are intended to provide practitioners
APPENDIX C
and institutions that deliver cardiovascular services with tools to measure
Reviewer Relationships With Industry and the quality of care provided and identify op-portunities for improvement.
Other Entities (Comprehensive) . . . . . . . . . . . . . . . . . 2562
Writing committees are instructed to consider the methodology of

performance measure development (1,2) and to ensure that the measures
TOP 10 TAKE-HOME MESSAGES FOR
ADULTS WITH HEART FAILURE developed are aligned with ACC/AHA clinical practice guidelines. The
writing committees also are charged with constructing measures that
1. This document describes performance measures for heart failure that maximally capture important aspects of care quality, including
are appropriate for public reporting or pay-for-performance programs. timeliness, safety, effectiveness, efficiency, equity, and patient-
2. The performance measures are from the 2017 Amer-ican College of centeredness, while minimizing, when possible, the reporting burden
Cardiology/American Heart Associa-tion/Heart Failure Society of imposed on hospi-tals, practices, and practitioners.
America heart failure guideline update and are selected from the
strongest recommendations (Class 1 or 3).
Potential challenges from measure implementation may lead to
3. Quality measures are also provided that are not yet ready for public unintended consequences. The manner in which challenges are addressed
reporting or pay for performance but might be useful for clinicians and is dependent on several factors, including the measure design, data
healthcare organi-zations for quality improvement. collection method, per-formance attribution, baseline performance rates,
reporting methods, and incentives linked to these reports.
4. A new safety measure (laboratory monitoring for pa-tients treated
with mineralocorticoid receptor antag-onists) is paired with a new
treatment measure
The ACC/AHA Task Force on Performance Measures (Task Force) measure tested to identify the consequences of measure implementation.
distinguishes quality measures from perfor-mance measures. Quality Quality measures may then be promoted to the status of performance
measures are those metrics that may be useful for local quality measures as supporting ev-idence becomes available.
improvement but are not yet appropriate for public reporting or pay for
perfor-mance programs (uses of performance measures). New measures P. Michael Ho, MD, PhD, FACC, FAHA Chair,
are initially evaluated for potential inclusion as performance measures. In ACC/AHA Task Force on Performance Measures
some cases, a measure is insufficiently supported by the guidelines. In
other in-stances, when the guidelines support a measure, the writing 1. INTRODUCTION
committee may feel it is necessary to have the
In 2019, the Task Force convened the writing committee to begin the
process of revising the existing performance
TABLE1
Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in
Patient Care* (Updated May 2019)
measures set for heart failure that was released in 2011 (3). The writing be avoided) guideline-recommended processes were considered for
committee also was charged with the task of developing new measures to inclusion as performance measures. The current Class of
evaluate the care of patients in accordance with the 2017 Recommendation and Level of Evidence guideline classification scheme
ACC/AHA/HFSA heart failure guideline update (4). used by the ACC and AHA in their clinical guidelines is shown in Table
1. The value (benefit and cost) of a process of care was also considered.
This updated performance measure set addresses in-hospital and If high-quality, published, cost-effectiveness studies indicate that a Class
continuing care in the outpatient setting. All Class 1 (strong) and 3 (no 1 guideline recommendation for a
benefit or harmful, process to
T A B L E 2 ACC/AHA 2020 Heart Failure Clinical Performance, Quality and Structural Measures
Measure Measure
No. Measure Title Care Setting Attribution Domain COR/LOE
PM-1 LVEF assessment Outpatient Individual practitioner, Facility Diagnostic COR: 1, LOE: C; COR: 2a, LOE: C
PM-2 Symptom and activity assessment Outpatient Individual practitioner, Facility Monitoring COR: 1, LOE: C
PM-3 Symptom management Outpatient Individual practitioner, Facility Treatment See measure rationale in
Appendix A for details
PM-4 Beta-blocker therapy for HFrEF Outpatient, Individual practitioner, Facility Treatment COR: 1, LOE: A; COR: 1, LOE: B
Inpatient
PM-5 ACE inhibitor or ARB or ARNI therapy for Outpatient, Individual practitioner, Facility Treatment COR: 1, LOE: A; COR: 1, LOE: B-R
HFrEF Inpatient
PM-6 ARNI therapy for HFrEF Outpatient, Individual practitioner, Facility Treatment COR: 1, LOE: B-R
Inpatient
PM-7 Dose of beta-blocker therapy for HFrEF Outpatient Individual practitioner, Facility Treatment COR: 1, LOE: A
PM-8 Dose of ACE inhibitor, ARB, or ARNI Outpatient Individual practitioner, Facility Treatment COR: 1, LOE: A; COR: 1, LOE: B-R
therapy for HFrEF
PM-9 MRA therapy for HFrEF Outpatient, Individual practitioner, Facility Treatment COR: 1, LOE: A; COR: 1, LOE: B
Inpatient
PM-10 Laboratory monitoring in new MRA therapy Outpatient, Individual practitioner, Facility Monitoring COR: 1, LOE: A
Inpatient
PM-11 Hydralazine/isosorbide dinitrate therapy Outpatient, Individual practitioner, Facility Treatment COR: 1, LOE: A
for HFrEF in those self-identified as Inpatient
Black or African American
PM-12 Counseling regarding ICD implantation for Outpatient Individual practitioner, Facility Treatment COR: 1, LOE: A
patients with HFrEF on guideline-
directed medical therapy
PM-13 CRT implantation for patients with HFrEF Outpatient Individual practitioner, Facility Treatment COR: 1, LOE: A; COR: 1, LOE: B
on guideline-directed medical therapy
Quality Measures
QM-1 Patient self-care education Outpatient Individual practitioner, Facility Self-Care COR: 1, LOE: B
QM-2 Measurement of patient-reported Outpatient Individual practitioner, Facility Monitoring See measure rationale in
outcome-health status Appendix A for details
QM-3 Sustained or improved health status in Outpatient Individual practitioner, Facility Outcome See measure rationale in
heart failure Appendix A for details
QM-4 Postdischarge appointment for patients Inpatient Individual practitioner, Facility Treatment COR: 2a, LOE: B
with heart failure
Structural Measure
SM-1 Heart failure registry participation Outpatient, Facility Structure COR: 2a, LOE: B
Inpatient
Rehabilitation Performance Measures Related to Heart Failure

(From the 2018 ACC/AHA performance measures for cardiac rehabilitation (6))
Rehab PM-2 Exercise training referral for HF from Inpatient Facility Process COR: 1, LOE: A
inpatient setting
Rehab PM-4 Exercise training referral for HF from Outpatient Individual practitioner, Facility Process COR: 1, LOE: A
outpatient setting
ACC indicates American College of Cardiology; ACE, angiotensin–converting enzyme; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–
neprilysin inhibitor; COR, class of recommendation; CRT, cardiac resynchronization therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable
cardioverter-defibrillator; LOE, level of evidence; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonists; PM, performance measure; QM, quality measure; and
SM, structural measure.
The writing committee developed a comprehensive heart failure

Associated ACC/AHA Clinical Practice Guidelines and
TABLE3 measure set that includes 18 measures: 13 performance measures, 4
Other Clinical Guidance Documents
quality measures, 1 structural
Clinical Practice Guidelines
measure, and 2 rehabilitation performance measures (from the 2018
2017 ACC/AHA/HFSA heart failure guideline update (4)
ACC/AHA performance measures for car-diac rehabilitation (6)), as
2016 ESC heart failure diagnosis and treatment guidelines (8)
reflected in Table 2 and Appendix A. The performance measures for
2013 ACCF/AHA heart failure clinical practice guideline (7)
heart failure included in the measure set are summarized in Table 2,
2017 AHA/ACC/HRS ventricular arrhythmias and prevention of sudden cardiac
death guideline (9)
which provides information on the measure number, measure title, and
care setting. The measure specifications (Appendix A) provide
information included in Table 2 and more detailed information
2011 ACCF/AHA/PCPI heart failure performance measurement set (3)
including, the measure description, numerator, denominator (i.e.,
2018 ACC/AHA performance measures for cardiac rehabilitation (6)
denominator exclusions and exceptions), rationale for the measure,
2017 ACC expert consensus decision pathway for optimization of heart failure
treatment (10) clinical practice guideline that supports the measure, measurement
period, source of data, and attribution.
ACC indicates American College of Cardiology; ACCF, American College of Cardiology
Foundation; AHA, American Heart Association; ESC, European Society of Cardiology;
HFSA, Heart Failure Society of America; HRS, Heart Rhythm Society; and PCPI, Physician
Consortium for Performance Improvement.
The writing committee recognized that the 2018 ACC/AHA
performance measures for cardiac rehabili-tation have been published
process of care is considered a poor value by ACC/AHA standards, then that address heart failure (6). The cardiac rehabilitation measure set
it was not included as a performance measure (5). There were no Class 1 includes performance measures for exercise training referral for
recommended pro-cesses of care judged to be of poor value. All inpatients and outpatients with heart failure and reduced left ventricular
ACC/AHA clinical practice guideline recommendations (including Class ejection fraction (Table 2). These rehabilitation measures also should be
2) were considered as potential quality measures. Ultimately, we selected consid-ered heart failure–related ACC/AHA performance measures.
measures based on their impor-tance for health, existing gaps in care,
ease of imple-mentation, potential duplication with other performance
measure lists, and risk for unintended consequences.
A comprehensive list of contraindications to care is not provided.
Instead, it is expected that clinical judgment
T A B L E 4 ACC/AHA Task Force on Performance Measures: Attributes for Performance Measures (11)
1. Evidence Based
High-impact area that is useful in improving a) For structural measures, the structure should be closely linked to a meaningful process of care that, in turn, is
patient outcomes linked to a meaningful patient outcome.
b) For process measures, the scientific basis for the measure should be well established, and the process should
be closely linked to a meaningful patient outcome.
c) For outcome measures, the outcome should be clinically meaningful. If appropriate, performance measures
based on outcomes should adjust for relevant clinical characteristics through the use of appropriate meth-
odology and high-quality data sources.
2. Measure Selection
Measure definition a) The patient group to whom the measure applies (denominator) and the patient group for whom conformance is
achieved (numerator) are clearly defined and clinically meaningful.
Measure exceptions and exclusions b) Exceptions and exclusions are supported by evidence.
Reliability c) The measure is reproducible across organizations and delivery settings.
Face validity d) The measure appears to assess what it is intended to.
Content validity e) The measure captures most meaningful aspects of care.
Construct validity f) The measure correlates well with other measures of the same aspect of care.
3. Measure Feasibility
Reasonable effort and cost a) The data required for the measure can be obtained with reasonable effort and cost.
Reasonable time period b) The data required for the measure can be obtained within the period allowed for data collection.
4. Accountability
Actionable a) Those held accountable can affect the care process or outcome.
Unintended consequences avoided b) The likelihood of negative, unintended consequences with the measure is low.
Reproduced with permission from Thomas et al (6). Copyright ª 2018, American Heart Association, Inc., and American College of Cardiology Foundation.
ACC indicates American College of Cardiology; and AHA, American Heart Association.
will be used to determine if a contraindication exists. For example,

Retired Heart Failure Measures From the
certain patients with heart failure and congen-ital heart disease would not
TABLE5
qualify for certain treatment measures and should be excluded from the
2011 Set (3)
denominator if documented by the clinician.
Rationale for
Although the measures are published as a set, their implementation Measure No. Care Setting Measure Title Retiring the Measure
can be individualized. It is not expected that all measures will be adopted

simultaneously. Although all the measures are considered valuable in 2 Inpatient LVEF assessment Inpatient documentation
of LVEF is at >97% (12).
improving care, we recognize that organizations may only be able to
focus on a limited number of measures. When implementing any measure LVEF indicates left ventricular ejection fraction.
that involves patient input, it is important to consider the patient’s health

excluded from voting on sections to which their specific RWI may apply.
literacy and adapt data collection accordingly. Performance measures are
a critical step in addressing disproportionately lower quality of care and
Any writing committee member who develops new RWI during his or
potentially worse health status and outcomes among an underserved
her tenure on the writing committee is required to notify staff in writing.
population.
These statements are reviewed period-ically by the Task Force and by
members of the writing com-mittee. Writing committee member and peer
reviewer RWI, which are pertinent to the document, are included in the
ap-pendixes: Appendix B for relevant writing committee RWI and
1.1. Scope of the Problem
Appendix C for comprehensive peer reviewer RWI. Addition-ally, to
Heart failure is a major and growing public health prob-lem in the United
ensure complete transparency, the writing committee members’
States with significant morbidity, mor-tality, and associated cost. A
comprehensive disclosure information, including RWI not relevant to the
detailed discussion of the scope of the problem and opportunities to
present document, is available online. Disclosure information for the
improve the quality of care that is provided to patients with this con-
Task Force is also available online.
dition is available in the ACCF/AHA 2013 heart failure clinical practice
guideline (7) and 2017 ACC/AHA/HFSA heart failure guideline update
(4). The work of the writing committee was supported exclusively by the
ACC and the AHA without commercial support. Members of the writing
committee volunteered their time for this effort. Meetings of the writing
1.2. Disclosure of Relationships With Industry and
com-mittee were confidential and attended only by writing committee
Other Entities
members and staff from the ACC, AHA, and the Heart Failure Society of
The Task Force makes every effort to avoid actual, potential, or America, which served as a collaborator on this project.
perceived conflicts of interest that could arise as a result of relationships
with industry or other entities (RWI). Informa-tion about the ACC/AHA
policy on RWI can be found online. All members of the writing
committee, as well as those selected to serve as peer reviewers of this
2. METHODOLOGY
document, were required to disclose all current relationships and those
existing within the 12 months before the initiation of this writing effort.
2.1. Literature Review
ACC/AHA policy also requires that the writing committee chair and at
least 50% of the writing committee have no relevant RWI. Writing In developing the updated heart failure measure set, the writing
committee members are committee reviewed evidence-based guidelines and statements that would
potentially impact the construct of the measures. The clinical practice
guidelines and scientific statements that most directly contributed to the
T A B L E 6 Revised Heart Failure Measures development of these measures are shown in Table 3.
Measure
No. Measure Title Description of Revision Rationale for Revision
5 Patient self-care education Moved from Performance Measure to Quality Concern regarding the accuracy of self-care education documentation;
Measure limited evidence of improved outcomes with better documentation.
7 ACE inhibitor or ARB therapy Added ARNI 2017 ACC/AHA/HFSA heart failure guideline update (4) made this revision to
for LVSD the recommendation.
9 Postdischarge appointment Moved from Performance Measure to Quality 2013 ACCF/AHA heart failure clinical practice guideline (7) lists postdischarge
Measure and included a time limit of 7 d appointment from 7-14 d as a Class 2a recommendation.
ACC indicates American College of Cardiology; ACE, angiotensin–converting enzyme; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–
neprilysin inhibitor; HF, heart failure; and LVSD, left ventricular systolic dysfunction.
T A B L E 7 New Heart Failure Measures
Measure Rationale for Creating Rationale for Designating as a Quality

No. Care Setting Measure Title New Measure Measure Versus a Performance Measure
PM-6 Outpatient, Inpatient ARNI therapy for HFrEF Important outcome benefit with N/A
large existing gap in care
PM-7 Outpatient Dose of beta-blocker therapy for HFrEF Important outcome benefit and N/A
PM-8 Outpatient Dose of ACE inhibitor, ARB, or ARNI therapy Important outcome benefit and N/A
for HFrEF large existing gap in care
PM-9 Outpatient, Inpatient MRA therapy for HFrEF Important outcome benefit and N/A
PM-10 Outpatient, Inpatient Laboratory monitoring in new Important outcome benefit and N/A
MRA therapy large existing gap in care
PM-11 Outpatient, Hydralazine/isosorbide dinitrate therapy for Important outcome benefit and N/A
Inpatient HFrEF in those self-identified as Black or large existing gap in care
African American
PM-13 Outpatient CRT implantation for patients with HFrEF on Important outcome benefit and N/A
guideline-directed medical therapy large existing gap in care
QM-2 Outpatient Measurement of patient-reported, outcome- Important outcome that is rarely Best method of implementation
health status measured is unclear
QM-3 Outpatient Sustained or improved health status Important outcome that is rarely Needs validated risk-adjustment
in heart failure measured
SM-1 Outpatient, Inpatient Heart failure registry participation Registries are a useful structure Additional data needed to determine
for measuring performance the impact of registry
participation on quality
ACE indicates angiotensin–converting enzyme; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; CRT, cardiac resynchronization therapy; HFrEF, heart
failure with reduced ejection fraction; MRA, mineralocorticoid receptor antagonists; N/A, not applicable; PM, performance measure; QM, quality measure; and SM, structural measure.
2.2. Definition and Selection of Measures 3.1.1. Retired Measures

The writing committee considered a number of additional factors, which The writing committee decided to retire the left ventric-ular ejection
are listed in Table 4. The potential impact, appropriateness for public fraction assessment measure used in the inpatient setting due to >97% of
reporting and pay for perfor-mance, validity, reliability, and feasibility use (12) (Table 5). Left ventricular ejection fraction assessment in the
were consid-ered. The writing committee examined available information outpatient setting was retained.
on current gaps in care. The term “heart failure” refers to stage C or D
heart failure unless other-wise stated (4).
3.1.2. Revised Measures

The writing committee reviewed and made changes to the patient self-
care education, angiotensin-converting enzyme inhibitor or angiotensin
3. ACC/AHA HEART FAILURE MEASURE SET receptor blocker ther-apy for left ventricular systolic dysfunction, and
post-discharge appointment measures, as summarized in Table 6. Table
3.1. Discussion of Changes to 2011 Heart Failure Measure Set 6 provides information on the updated measures including the care
After reviewing the existing clinical practice guidelines, and the 2011 setting, title, and a brief rationale for revisions made to the measures.
ACCF/AHA/PCPI heart failure performance measurement set (3), the
writing committee discussed which measures required revision to reflect
updated sci-ence related to heart failure and identified which guide-line
recommendations could serve as the basis for new performance or quality 3.1.3. New Measures
measures. The writing committee also reviewed existing publicly The writing committee created 7 new performance mea-sures (PM 6-11,
available measure sets. 13), 2 quality measures (QM 2, 3), and 1 structural measure (SM-1)
(Table 7). Six of the new per-formance measures were based on Class 1
These subsections serve as a synopsis of the revisions that were made guideline rec-ommendations for therapies known to prolong survival. An
to previous measures and a description of why the new measures were additional performance measure (PM-10, measure-ment of potassium
created for both the inpatient and outpatient setting. after a mineralocorticoid receptor
antagonist prescription) is also guideline recommended and included as a tion of the measure set, the writing committee was un-able to include
safety measure to accompany pre-scription for mineralocorticoid receptor them in the measure set.
antagonist (PM-
9) . Two new measures based on dose were created (PM-7 and PM-8).
STAFF
These were chosen because of the gap be-tween doses used in practice
and those shown to provide survival benefit in clinical trials. They were
American College of Cardiology
designed to apply only to those patients without demonstrated intolerance
Athena Poppas, MD, FACC, President
at higher doses.
Cathleen Gates, Interim Chief Executive Officer
John S. Rumsfeld, MD, PhD, FACC, Chief Science and Quality Officer
For more detailed information on each measure’s construct, refer to
the specifications in Appendix A.
Lara Slattery, Division Vice President, Clinical Registry and
4. AREAS FOR FURTHER RESEARCH Accreditation
Grace Ronan, Team Lead, Clinical Policy Publication Timothy W.
There are multiple ways that cardiac rehabilitation and exercise Schutt, MA, Clinical Policy Analyst
prescriptions can be implemented (13). Further studies are needed to
determine if there are differences in the magnitude of outcome American College of Cardiology/American Heart Association Abdul R.
improvements by approach. Similarly, although patient-reported Abdullah, MD, Director, Guideline Science and
outcomes are considered an important metric, the best way to measure Methodology
these needs additional research. Two surveys are well validated: The Rebecca L. Diekemper, MPH, Guideline Advisor,
Kansas City Cardiomyopathy Questionnaire (14) and the Minnesota Performance Measures
Living with Heart Failure Questionnaire (15). However, risk-adjustment American Heart Association
is required to fairly compare groups for use as an outcome measure. The Robert A. Harrington, MD, FAHA, President Nancy
collection of the measure (process of care) does not require risk- Brown, Chief Executive Officer
adjustment but will benefit from additional research to understand Mariell Jessup, MD, FAHA, Chief Science and Medical Officer
optimal timing of collection of patient-reported outcomes, including fre-
quency and relation to the clinic visit. Finally, data supporting sodium- Radhika Rajgopal Singh, PhD, Vice President, Office of Science,
glucose cotransporter-2 inhibitors are emerging for heart failure Medicine, and Health
treatment; however, with additional trials ongoing and having not been Paul St. Laurent, DNP, RN, Senior Science and Medicine Advisor
integrated into guideline recommendations at the time of genera-
Melanie Shahriary, RN, BSN, Senior Manager, Performance Metrics,
Quality and Health IT
Jody Hundley, Production and Operations Manager, Scientific
Publications, Office of Science Operations
guideline for the management of heart failure: a report of

the American College of Cardiology/American Heart
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PA, et al. Temporal trends in clinical characteristics, KEY WORDS ACC/AHA Performance Measures,
treatments, and outcomes for heart failure heart failure, performance measures, quality
hospitalizations, 2002 to 2004: findings from Acute indicators, quality measures
Decompensated Heart
APPENDIX A. HEART FAILURE MEASURE SET
Performance Measures for Heart Failure
SHORTTITLE:PM-1 Left Ventricular Ejection Fraction Assessment (Outpatient Setting)
PM-1: Left Ventricular Ejection Fraction Assessment (Outpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure for whom the quantitative result of prior (any time in the past) LVEF assessment,
using any imaging modality, is available in the medical record
Numerator Patients for whom the quantitative* results of prior (any time in the past) LVEF assessment, using any imaging modality, is available in
the medical record (includes note documentation)
*Single value or numerical range
Denominator All patients age $18 y with a diagnosis of heart failure
Denominator Exclusions Heart transplant

LVAD
Denominator Exceptions Documentation of medical reason(s) for not evaluating LVEF (e.g., comfort care only)
Documentation of patient reason(s) for not evaluating LVEF (e.g., patient refusal)
Measurement Period 12 mo
Sources of Data EHR data

Administrative data/claims (inpatient or outpatient claims)
Administrative data/claims expanded (multiple sources)
Paper medical record
Attribution Individual practitioner

Facility
Care Setting Outpatient
Rationale
Evaluation of LVEF in patients with heart failure provides important information that is required to appropriately direct treatment. Several pharmacological therapies have
demonstrated efficacy in slowing disease progression and improving survival in patients with left ventricular systolic dysfunction (3).
Although most patients have an LVEF recorded, this remains a performance measure because knowledge of LVEF is required to determine eligibility for appropriate heart
failure care.
Patients post–heart transplant or with an LVAD are excluded, because these patients were excluded from clinical treatment trials for low LVEF heart failure.
Clinical Recommendation(s)

1. A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall
motion, and valve function. (Class 1, Level of Evidence: C)
2. Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical
status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may
be candidates for device therapy. (Class 1, Level of Evidence: C)
3. Radionuclide ventriculography or magnetic resonance imaging can be useful to assess LVEF and volume when echocardiography is inadequate. (Class 2a, Level of Evidence: C)
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; EF, ejection fraction; EHR, electronic health record; GDMT, guideline-directed medical
therapy; HF, heart failure; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; and PM, performance measure.
APPENDIX A. CONTINUED
SHORTTITLE:PM-2 Symptom and Activity Assessment (Outpatient Setting)
PM-2: Symptom and Activity Assessment (Outpatient Setting)
Measure Description: Percentage of patient visits for those patients age $18 y with a diagnosis of heart failure with quantitative results of an evaluation of both current level of
activity and clinical symptoms documented
Numerator Patient visits with quantitative results of an evaluation of both current level of activity and clinical symptoms documented*
*Evaluation and quantitative results documented can include:

n Documentation of NYHA class or
n Documentation of completion of a valid, reliable, disease-specific instrument (e.g., KCCQ or MLHFQ)
Numerator Definitions/Instructions:
The NYHA functional classification reflects a subjective assessment by a healthcare provider of the severity of a patient’s symp-toms.
Patients are assigned to one of the following classes:
n Class I: Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitation, dyspnea, or anginal pain.
n Class II: Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary
physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
n Class III: Patients with marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue,
palpitation, dyspnea, or anginal pain.
n Class IV: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.
Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort
is increased.
Patient-reported health status as assessed by a structured survey/questionnaire instrument offers another, more patient-centric
approach to assessing and summarizing the patient’s overall heart failure symptom burden. These instruments serve as important
constructs for delivering and evaluating heart failure care.
Denominator All patient visits for those patients age $18 y with a diagnosis of heart failure
LVAD
Denominator Exceptions Documentation of medical reason(s) for not evaluating both current level of activity and clinical symptoms (e.g.,
severe cognitive or functional impairment)
Documentation of patient reason(s) for not evaluating both current level of activity and clinical symptoms

Facility

Rationale
Initial and ongoing evaluations of patients with heart failure should include an assessment of symptoms and their functional consequences. These assessments serve as the
basis for making treatment decisions, monitoring the effects of treatment, and modifying treatment as appropriate. Decreasing symptoms and improving function are 2 of
the primary goals of heart failure treatment and represent important patient-centric outcomes for heart failure care.
The ACC/AHA have not addressed PRO tool selection. However, the FDA has provided guidelines for an appropriate PRO tool (16) and, currently, 2 heart failure survey tools
—the MLHFQ (15) and the KCCQ (14)—are considered qualified tools for FDA device use in heart failure (17).

1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that
might cause or accelerate the development or progression of HF. (Class 1, Level of Evidence: C)
2. The NYHA functional classification gauges the severity of symptoms in those with structural heart disease. Although reproducibility and validity may be problematic (18),
the NYHA functional classification is an independent predictor of mortality (19). It is widely used in clinical practice and research and for determining the eligibility of patients for certain
healthcare services (7). However, NYHA functional class assessment is not reported in a significant number of patients in contemporary HF practices in the United States (20).
3. Evaluate general health status (see Figure 2, 2013 ACCF/AHA guideline) (7).
Although no specific 2013 ACCF/AHA guideline recommendation is made regarding collection of NYHA or other quantitative result, knowledge of symptom status is needed
to determine candidacy for appropriate HF treatments (7).
ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; FDA, U.S. Food and
Drug Administration; HF, heart failure; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVAD, left ventricular assist device; MLHFQ, Minnesota Living with Heart Failure Ques-tionnaire;
NYHA, New York Heart Association; PM, performance measure; and PRO, patient-reported outcome.
SHORTTITLE:PM-3 Symptom Management (Outpatient Setting)
PM-3: Symptom Management (Outpatient Setting)
Measure Description: Percentage of patient visits for those patients age $18 y with a diagnosis of heart failure and with quantitative results of an evaluation of both level of
activity and clinical symptoms documented in which patient symptoms have improved or remained consistent with treatment goals, or patient symptoms have worsened
since last assessment and have a documented plan of care
Numerator Patient visits in which patient symptoms have improved or remained consistent with treatment goals since last assessment,* or patient
symptoms have worsened since last assessment* and have a documented plan of care†
*Examples of quantitative assessment:

n NYHA class or
n A valid, reliable, disease-specific instrument (e.g., KCCQ [clinically important deterioration can be classified as a 5-point reduction in the overall
summary score] or MLHFQ [clinically important deterioration can be classified as a 10-point increase in
the total score])
n 6-Minute Walk Test
n Peak oxygen consumption (VO2) or the slope of minute ventilation to carbon dioxide production (VE/VCO 2 slope)
†A documented plan of care may include $1 of the following: reevaluation of medical therapy including up-titration of medication doses,
consideration of electrical device therapy, recommended lifestyle modifications (e.g., salt restriction, exercise training), initiation of
palliative care, referral for more advanced therapies (e.g., cardiac transplant, ventricular assist device), or referral to disease management
programs.
Denominator All patient visits for those patients age $18 y with a diagnosis of heart failure and with quantitative results of an evaluation of both level
of activity and clinical symptoms documented at the time of the encounter and at a prior time point 1 to 12 mo previously.

LVAD
Denominator Exceptions None


Facility
Rationale
Heart failure significantly decreases HRQOL, especially in the areas of physical functioning and vitality (21,22). Lack of improvement in HRQOL after discharge from the
hospital is a powerful predictor of rehospitalization and mortality (23,24). Women with heart failure have consistently been found to have worse HRQOL than men (22,25).
Ethnic differences also have been found, with Mexican Hispanics reporting better HRQOL than other ethnic groups in the United States (26). Other determinants of poor
HRQOL include depression, younger age, higher BMI, greater symptom burden, lower systolic blood pressure, sleep apnea, low perceived control, and uncertainty about
prognosis (25,27–31).
Objective data on symptoms and functional status from at least 2 time points are needed to decide if patients are benefitting from therapy.

1. Goals of treatment in heart failure are to improve health-related quality of life and symptoms (see Figure 3, 2013 ACCF/AHA guideline) (7).
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; BMI, body mass index; EHR, electronic health record; ICC, intraclass correlation co-efficient;
HRQOL, health-related quality of life; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVAD, left ventricular assist device; MLHFQ, Minnesota Living with Heart Failure Questionnaire;
NYHA, New York Heart Association; PM, performance measure; PRO, patient-reported outcome; VE/VCO 2, ventilation and carbon dioxide; and VO2, oxygen consumption.
SHORTTITLE:PM-4 Beta-Blocker Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting)
PM-4: Beta-Blocker Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% who were prescribed beta-blocker therapy either
within a 12-mo period when seen in the outpatient setting or at hospital discharge
Numerator Patients who were prescribed* beta-blocker therapy† either within a 12-mo period when seen in the outpatient setting or at hospital
discharge
*Prescribed may include:

n Outpatient setting: Prescription for beta blocker given to the patient for beta-blocker therapy at $1 visits in the 12-mo measurement
period or patient already taking beta-blocker therapy as documented in current medication list.
n Inpatient setting: Prescription given to the patient for beta-blocker therapy at discharge or beta-blocker therapy to be continued after
discharge as documented in the discharge medication list.
†Beta-blocker therapy should include bisoprolol, carvedilol, or sustained-release metoprolol succinate (see technical specifications
for additional information on medications).
Denominator All patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40%

LVAD
Denominator Exceptions Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., intolerance)
Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient refusal)


Facility

Inpatient
Rationale
Beta blockers improve survival and reduce hospitalization for patients with stable heart failure and reduced LVEF (HFrEF) (7). Treatment should be initiated as soon as a
patient is diagnosed with reduced LVEF and does not have prohibitively low systemic blood pressure, fluid overload, or recent treatment with an intravenous positive
inotropic agent. Beta blockers have also been shown to lessen the symptoms of heart failure, improve the clinical status of patients, and reduce future clinical
deterioration. Despite these benefits, use of beta blockers in eligible patients remains suboptimal (20).
1. Use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with
current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality (32–37). (Class 1, Level of Evidence: A)
2. Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic
agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Caution should be used when initiating beta blockers in patients who have required inotropes
during their hospital course (38–40). (Class 1, Level of Evidence: B)
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; HFrEF, heart failure reduced ejection fraction; LVAD, left
ventricular assist device; LVEF, left ventricular ejection fraction; and PM performance measure.
Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker or Angiotensin Receptor-

SHORTTITLE:PM-5 Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting)
PM-5: Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker or Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced
Ejection Fraction (Outpatient and Inpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% who were prescribed ACE inhibitor, ARB, or ARNI
either within a 12-mo period when seen in the outpatient setting or at hospital discharge
Numerator Patients who were prescribed* ACE inhibitor, ARB, or ARNI either within a 12-mo period when seen in the outpatient setting or at
hospital discharge

n Outpatient setting: Prescription given to the patient for ACE inhibitor, ARB, or ARNI at $1 visits in the 12-mo
measurement period or patient already taking ACE inhibitor, ARB, or ARNI as documented in current medication list.
n Inpatient setting: Prescription given to the patient for ACE inhibitor, ARB, or ARNI at discharge or ACE inhibitor, ARB, or
ARNI to be continued after discharge as documented in the discharge medication list.
Denominator All patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40%

LVAD
Denominator Exceptions Documentation of medical reason(s) for not prescribing ACE inhibitor, ARB, or ARNI (e.g., intolerance)
Documentation of patient reason(s) for not prescribing ACE inhibitor, ARB, or ARNI (e.g., patient refusal)
Measurement Period ACE inhibitor, ARB, or ARNI therapy initiated within a 12-mo period of being seen in the outpatient setting or from hospital
discharge


Facility

Inpatient
Rationale
Use of ACE inhibitor, ARB, or ARNI therapy has been associated with improved outcomes in patients with reduced LVEF (7).
Long-term therapy with ARBs has also been shown to reduce morbidity and mortality, especially in ACE inhibitor–intolerant patients (41–44). More recently, ARNI therapy has
also been shown to more significantly improve outcomes (45), such that the newest guidelines recommend replacement of ACE inhibitors or ARBs with ARNI therapy in
eligible patients (4). However, despite the benefits of these drugs, use of ACE inhibitor, ARB, or ARNI remains suboptimal (20).
1. The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors (Class 1, Level of Evidence: A) (46–51), OR ARBs (Class 1, Level of
Evidence: A) (41–44), OR ARNI (Class 1, Level of Evidence: B-R) (45) in conjunction with evidence-based beta blockers (7,33,52), and aldosterone antagonists in
selected patients (53,54), is recommended for patients with chronic HFrEF to reduce morbidity and mortality.
ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; ACE, angiotensin–converting enzyme; AHA, American Heart Association; ARB,
angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; EHR, electronic health record; HFrEF, heart failure reduced ejection fraction; HFSA, Heart Failure Society of
America; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; and PM, performance measure.
SHORTTITLE:PM-6
Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient
and Inpatient Setting)
PM-6: Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% who remained symptomatic at NYHA functional
class II or class III despite ACE inhibitor or ARB therapy for a least 3 mo and were prescribed ARNI therapy either within a 12-mo period when seen in the outpatient
setting or at hospital discharge
Numerator Patients who were prescribed* ARNI therapy either within a 12-mo period when seen in the outpatient setting or at hospital
discharge

n Outpatient setting: Prescription given to the patient for ARNI therapy at $1 visits in the measurement period or patient
already taking ARNI therapy as documented in current medication list.
n Inpatient setting: Prescription given to the patient for ARNI at discharge or ARNI therapy to be continued after discharge
as documented in the discharge medication list.
Denominator All patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% after 3 mo of ACE inhibitor or ARB
therapy

LVAD
NYHA class I and class IV
Denominator Exceptions Documentation of medical reason(s) for not prescribing ARNI therapy (e.g., intolerant)
Documentation of patient reason(s) for not prescribing ARNI therapy (e.g., patient refusal, cost)
Documentation of system reason(s) for not prescribing ARNI therapy
Measurement Period ARNI therapy initiated within a 12-mo period of being seen in the outpatient setting or from hospital discharge


Facility

Inpatient
Rationale
In a large randomized clinical trial, an ARNI (valsartan/sacubitril) was compared with an ACE inhibitor (enalapril) in symptomatic patients with HFrEF. The ARNI reduced the
composite endpoint of cardiovascular death or heart failure hospitalization significantly, by 20% (45). The benefit was seen to a similar extent for both death and heart
failure hospitalization and was consistent across subgroups. Since the initial large randomized clinical trial with ARNI, there has been additional clinical trial evidence
(55,56), meta-analyses (57), and observational clinical effectiveness studies (58), which further support the use of valsartan/sacubitril in replacement of ACE inhibitor or
ARB therapy to reduce mortality and morbidity.
1. 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 (45). (Class 1, Level of Evidence: ARNI: B-R)
angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; EHR, electronic health record; HFrEF, heart failure reduced ejection fraction; HFSA, Heart Failure Society of
America; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; and PM, performance measure.
SHORTTITLE:PM-7 Dose of Beta-Blocker Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient Setting)
PM-7: Dose of Beta-Blocker Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% who were prescribed a guideline-recommended
beta blocker (e.g., bisoprolol, carvedilol, or sustained-release metoprolol succinate) at a dose that is at least 50% of the target dose (see Table A for target doses)
Numerator Patients who were prescribed a guideline-recommended beta blocker at a dose that is at least 50% of the target dose (see Table A
for target doses)
Denominator All patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% who were prescribed a recommended
beta blocker

LVAD
Denominator Exceptions Documentation of intolerance of higher dose or medical reason(s) for not prescribing higher dose of beta blocker
Documentation of patient reason(s) for not prescribing higher dose of beta blocker
Documentation of system reason(s) for not prescribing higher dose of beta blocker
Measurement Period Annually


Facility

Rationale
Use of guideline-recommended beta blockers has been proven to reduce morbidity and mortality in patients with HFrEF, and studies have supported a dose-response
relationship of beta blockers with improved outcomes (59–64). These findings suggest that, among HFrEF patients in whom target doses might be well tolerated, treating
at less than the target dose may result in worse clinical outcomes. Despite guideline recommendations for clinicians to achieve target doses of beta blockers shown to be
effective in major clinical trials, the percentage of patients achieving these doses is low and remains low over time (20,65,66).
Treatment with a beta blocker should be initiated at very low doses, followed by gradual incremental increases in dose if lower doses have been well tolerated. Clinicians
should make every effort to achieve the target doses of the beta blockers shown to be effective in major clinical trials (7).
1. Use of 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior
symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality (32–37). (Class 1, Level of Evidence: A)
2017 ACC expert consensus decision pathway for optimization of heart failure treatment (10)
1. After a diagnosis of heart failure is made, GDMT should be initiated and therapies should be adjusted no more frequently than every 2 weeks to target doses (or maximally tolerated
doses).
2. To achieve the maximal benefits of GDMT in patients with chronic HFrEF, therapies must be initiated and titrated to maximally tolerated doses (33,45,60,67).
ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; GDMT, guideline-
directed medical therapy; HFrEF, heart failure reduced ejection fraction; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; and PM, performance measure.
T A B L E A Target Doses of Guideline-Directed Medical Therapies
ACE Inhibitors Target Dose Total Daily Target Dose 50% of Total Daily Target Dose
Captopril 50 mg, three times daily 150 mg 75 mg
Enalapril 10 mg, twice daily 20 mg 10 mg
Lisinopril 20 mg, once daily 20 mg 10 mg
Ramipril 10 mg, once daily 10 mg 5 mg
Perindopril 8 mg, once daily 8 mg 4 mg
Trandolapril 4 mg, once daily 4 mg 2 mg
Benazepril 40 mg, once daily 40 mg 20 mg
Fosinopril 40 mg, once daily 40 mg 20 mg
Quinapril 20 mg, twice daily 40 mg 20 mg
ARB
Candesartan 32 mg, once daily 32 mg 16 mg
Losartan 100 mg, once daily* 100 mg 50 mg
Valsartan 160 mg, twice daily 320 mg 160 mg
Irbesartan 300 mg, once daily 300 mg 150 mg
Telmisartan 80 mg, once daily 80 mg 40 mg
Olmesartan 40 mg, once daily 40 mg 20 mg
Azilsartan 80 mg, once daily 80 mg 40 mg
ARNI
Sacubitril/valsartan 97/103 mg, twice daily 194/206 mg 98/102 mg†
Evidence-Based Beta-Blockers
Bisoprolol 10 mg, once daily 10 mg 5 mg
Carvedilol 25 mg, twice daily 50 mg 25 mg
Carvedilol extended release 80 mg, once daily 80 mg 40 mg
Metoprolol succinate sustained release 200 mg, once daily 200 mg 100 mg
Sources for target doses include: 2013 ACCF/AHA heart failure clinical practice guideline (7), 2017 ACC/AHA/HFSA heart failure guideline update (4), 2017 ACC expert consensus decision
pathway for optimization of heart failure treatment (10), and FDA-approved labels (68).
*ACC/AHA Guidelines recommend losartan 150 mg as target dose. However, because current FDA-approved labeling has 100 mg as the maximal dose, the 100-mg dose is used in the
performance measure.
†The sacubitril 98 mg and valsartan 102 mg total daily dosing (49/51 mg twice daily) is considered fulfilling the 50% of target dosing criteria.
ACE indicates angiotensin–converting enzyme; ARB, angiotensin II receptor blocker; and ARNI, angiotensin receptor–neprilysin inhibitor.
Dose of Angiotensin-Converting Enzyme Inhibitor, Angiotensin Receptor Blocker, or Angiotensin

SHORTTITLE:PM-8 Receptor-Neprilysin Inhibitor Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient Setting)
PM-8: Dose of Angiotensin-Converting Enzyme Inhibitor, Angiotensin Receptor Blocker, or Angiotensin Receptor-Neprilysin Inhibitor Therapy for Heart Failure With
Reduced Ejection Fraction (Outpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% who were prescribed an ACE inhibitor, ARB, or
ARNI at a dose that is at least 50% of the target dose (see Table A for target doses)
Numerator Patients who were prescribed an ACE inhibitor, ARB, or ARNI at a dose that is at least 50% of the target dose (see Table A for
target doses)
Denominator All patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #40% who were prescribed an ACE inhibitor,
ARB, or ARNI

LVAD
Denominator Exceptions Documentation of intolerance of higher dose or medical reason(s) for not prescribing higher dose of ACE inhibitor, ARB, or ARNI
Documentation of patient reason(s) for not prescribing higher dose of ACE inhibitor, ARB, or ARNI
Documentation of system reason(s) for not prescribing higher dose of ACE inhibitor, ARB, or ARNI
Measurement Period Annually


Facility

Rationale
Inhibition of the renin-angiotensin system with ACE inhibitor, ARB, or ARNI therapy has been proven to reduce morbidity and mortality in patients with HFrEF, and studies
have supported a dose-response relationship of these therapies with improved outcomes (42,50,69,70). These findings suggest that, among HFrEF patients in whom
target doses might be well tolerated, treating at less than the target dose may result in worse clinical outcomes. Despite guideline recommendations for clinicians to
achieve target doses of ACE inhibitors, ARBs, or ARNIs, the number of patients achieving these doses is low and remains low over time (20,65,66).
1. The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors (Class 1, Level of Evidence: A) (46–51), OR ARBs (Class 1, Level of
Evidence: A) (41–44), OR ARNI (Class 1, Level of Evidence: B-R) (45) in conjunction with evidence-based beta blockers (7,33,52), and aldosterone antagonists in
selected patients (53,54), is recommended for patients with chronic HFrEF to reduce morbidity and mortality.
2. ACE inhibitors should be started at low doses and titrated upward to doses shown to reduce the risk of cardiovascular events in clinical trials.
3. ARBs should be started at low doses and titrated upward, with an attempt to use doses shown to reduce the risk of cardiovascular events in clinical trials. 2017 ACC expert consensus
decision pathway for optimization of heart failure treatment (10)
1. After a diagnosis of heart failure is made, GDMT should be initiated and therapies should be adjusted no more frequently than every 2 weeks to target doses (or maximally tolerated
doses).
2. To achieve the maximal benefits of GDMT in patients with chronic HFrEF, therapies must be initiated and titrated to maximally tolerated doses (33,45,60,67).
angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; EHR, electronic health record; GDMT, guideline-directed medical therapy; HFrEF, heart failure reduced ejection
fraction; HFSA, Heart Failure Society of America; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; and PM, performance measure.
SHORTTITLE:PM-9
Mineralocorticoid Receptor Antagonist Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient
and Inpatient Setting)
PM-9: Mineralocorticoid Receptor Antagonist Therapy for Heart Failure With Reduced Ejection Fraction (Outpatient and Inpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #35% who are NYHA class II through class IV despite
attempts at treatment with beta blockers and ACE inhibitors, ARB, or ARNI
Numerator Patients who were prescribed* MRA either within a 12-mo period when seen in the outpatient setting or at hospital discharge

n Outpatient setting: Prescription given to the patient for MRA therapy at $1 visits in the measurement period or patient already taking
MRA therapy as documented in current medication list.
n Inpatient setting: Prescription given to the patient for MRA therapy at discharge or MRA therapy to be continued after discharge as
documented in the discharge medication list.
Denominator All patients age $18 y with a diagnosis of heart failure with a current or prior LVEF #35% who are NYHA class II-IV despite
attempts at treatment with beta blockers and ACE inhibitors, ARB, or ARNI, and have Cr #2.5 mg/dL for men and #2.0 mg/dL for
2
women (or estimated glomerular filtration rate >30 mL/min/1.73 m ) and K <5.0 mEq/L
LVAD
Denominator Exceptions Documentation of medical reason(s) for not prescribing MRA therapy
Documentation of patient reason(s) for not prescribing MRA therapy


Facility

Inpatient
Rationale
MRA therapy improves outcome in patients with heart failure and reduced LVEF (7). Use of MRA therapy in those without contraindications was 33% among 150 primary care
and cardiology practices in the CHAMP-HF registry demonstrating a moderate to large treatment gap (20).
1. Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II–IV HF and who have LVEF of 35% or less,
unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II HF should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide
levels to be considered for aldosterone receptor antagonists. Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate >30
2
mL/min/1.73 m ), and potassium should be less than 5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely followed
thereafter to minimize risk of hyperkalemia and renal insufficiency (54,71,72). (Class 1, Level of Evidence: A)
2. Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of 40% or less who develop
symptoms of HF or who have a history of diabetes mellitus, unless contraindicated (73). (Class 1, Level of Evidence: B)
ACCF indicates American College of Cardiology Foundation; ACE, angiotensin–converting enzyme; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNI, angiotensin
receptor–neprilysin inhibitor; CHAMP-HF, CHAnge the Management of Patients with Heart Failure; Cr, creatinine; EHR, electronic health record; HF, heart failure; LVAD, left ventricular
assist device; LVEF, left ventricular ejection fraction; MI, myocardial infarction; MRA, mineralocorticoid receptor antagonist; NYHA, New York Heart Association; and PM, performance
measure.
SHORTTITLE:PM-10
Laboratory Monitoring in New Mineralocorticoid Receptor Antagonist Therapy (Outpatient and Inpatient Setting)
PM-10: Laboratory Monitoring in New Mineralocorticoid Receptor Antagonist Therapy (Outpatient and Inpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure who were started on MRA therapy and had potassium and renal function checked
within 1 wk of the patient initiation of the MRA prescription
Numerator Patients who had potassium and renal function checked within 1 wk of the patient initiation of the MRA prescription
Denominator All patients age $18 y with a diagnosis of heart failure who filled a new prescription for MRA therapy

LVAD


Facility

Inpatient
Rationale
The major risk associated with use of aldosterone receptor antagonists is hyperkalemia attributable to inhibition of potassium excretion, ranging from 2% to 5% in trials
(54,72,73) to 24% to 36% in population-based registries (74,75). The development of potassium levels >5.5 mEq/L (approximately 12% in EMPHASIS-HF (72)) should
trigger discontinuation or dose reduction of the aldosterone receptor antagonist unless other causes are identified. The development of worsening renal function should
lead to careful evaluation of the entire medical regimen and consideration for stopping the aldosterone receptor antagonist (7). Close monitoring of serum potassium is
required; potassium levels and renal function are most typically checked in 3 d and at 1 wk after initiating therapy and at least monthly for the first 3 mo (Table 17, 2013
ACCF/AHA guideline (7)).
Despite the known risk of hyperkalemia with MRA initiation, the rate of measurement of potassium levels within 2 wk of initiation is low (76).
Although the clinical guideline suggests checking in 3 d, this is not a formal recommendation. Thus, the writing committee chose a more conservative 7-d time period to allow
patient and provider flexibility and acknowledge challenges with weekend and holiday laboratory assessments.
1. Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II–IV HF and who have LVEF of 35% or less, unless
contraindicated, to reduce morbidity and mortality. Patients with NYHA class II HF should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels
to be considered for aldosterone receptor antagonists. Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate >30
2
mL/min/1.73 m ), and potassium should be less than 5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely followed
thereafter to minimize risk of hyperkalemia and renal insufficiency (54,71,72). (Class 1, Level of Evidence: A)
2. Inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine is greater than 2.5
2
mg/dL in men or greater than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m ), and/or potassium greater than 5.0 mEq/L (74,75). (Class 3, Harm, Level of
Evidence: B)
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; EMPHASIS-HF, Eplerenone in Mild Patients Hospitalization
And SurvIval Study in Heart Failure; HF, heart failure; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; NYHA, New
York Heart Association; and PM, performance measure.
SHORTTITLE:PM-11
Hydralazine/Isosorbide Dinitrate Therapy for Heart Failure With Reduced Ejection Fraction in Those Self-Identified
as Black or African American (Outpatient and Inpatient Setting)
PM-11: Hydralazine/Isosorbide Dinitrate Therapy for Heart Failure With Reduced Ejection Fraction in Those Self-Identified as Black or African American (Outpatient and
Inpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure and a current or prior ejection fraction #40% who are self-identified as Black or African
American and receiving ACE inhibitor, ARB, or ARNI therapy and beta-blocker therapy who were prescribed a combination of hydralazine and isosorbide dinitrate
Numerator Patients who were prescribed* hydralazine and isosorbide dinitrate or fixed dose combination of hydralazine/isosorbide dinitrate
within a 12-mo period when seen in the outpatient setting or at hospital discharge

n Outpatient setting: Prescription given to the patient for hydralazine/isosorbide dinitrate therapy at $1 visits in the
measurement period or patient already taking hydralazine/isosorbide dinitrate therapy as documented in current
medication list.
n Inpatient setting: Prescription given to the patient for hydralazine/isosorbide dinitrate therapy at discharge or hy-
dralazine/isosorbide dinitrate therapy to be continued after discharge as documented in the discharge medication list.
Use of formulations of nitrates other than isosorbide dinitrate do not meet the numerator requirements.
Denominator All patients age $18 y with a diagnosis of heart failure (NYHA class III or class IV) with a current or prior LVEF #40% who are self-
identified as Black or African American and receiving ACEI, ARB, or ARNI, and beta-blocker therapy

LVAD
Denominator Exceptions Documentation of medical reason(s) for not prescribing hydralazine/isosorbide dinitrate therapy
Documentation of patient reason(s) for not prescribing hydralazine/isosorbide dinitrate therapy
Measurement Period Hydralazine/isosorbide dinitrate therapy initiated within a 12-mo period of being seen in the outpatient setting or from hospital
discharge


Facility

Inpatient
Rationale
The combination of hydralazine and isosorbide dinitrate is recommended to improve outcomes for patients self-identified as African American or Black, who have moderate-
to-severe symptoms on optimal medical therapy (7). Use of hydralazine and isosorbide dinitrate in self-identified African American or Black candidates for therapy has
been suboptimal (77).
1. The combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients self-described as African Americans with NYHA
class III–IV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers, unless contraindicated (78,79). (Class 1, Level of Evidence: A)
receptor–neprilysin inhibitor; EHR, electronic health record; HFrEF, heart failure reduced ejection fraction; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; NYHA,
New York Heart Association; and PM, performance measure.
Counseling Regarding Implantable Cardioverter-Defibrillator Implantation for Patients With Heart

SHORTTITLE:PM-12
Failure With Reduced Ejection Fraction on Guideline-Directed Medical Therapy (Outpatient Setting)
PM-12: Counseling Regarding Implantable Cardioverter-Defibrillator Implantation for Patients With Heart Failure With Reduced Ejection Fraction on Guideline-Directed
Medical Therapy (Outpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with current LVEF #35% despite ACE inhibitor, ARB, or ARNI and beta-blocker
therapy for at least 3 mo who were counseled regarding ICD implantation as a treatment option for the prophylaxis of sudden death
Numerator Patients who were counseled* regarding ICD implantation as a treatment option for the prophylaxis of sudden death
*Counseling should be specific to each individual patient and include documentation of a discussion regarding the risk of sudden
and non-sudden death and the efficacy, safety, and risks of an ICD. This will allow patients to be informed of the risks and benefits
of ICD implantation and better able to make decisions based on the valuation of sudden cardiac death versus other risks.
Denominator All patients age $18 y with a diagnosis of heart failure with current LVEF #35% despite ACE inhibitor, ARB, or ARNI and beta-
blocker therapy for at least 3 mo
Denominator Exclusions Functional ICD in situ

Heart transplant
LVAD
Denominator Exceptions Documentation of medical reason(s) for not providing counseling regarding ICD implantation as a treatment option for the
prophylaxis of sudden death (e.g., significant comorbidities, limited life expectancy, up titration of medical therapy is ongoing with
anticipated LVEF improvement)


Facility
Rationale
ICDs prevent sudden death due to ventricular tachyarrhythmias in select patients with HFrEF (7). However, frequent or inappropriate shocks from an ICD can lead to reduced
quality of life. Patients may differ in the willingness to have an ICD implanted based on their preferences for quality and length of life. Given the significant risks and
benefits of ICD implantation, eligible patients should be fully informed of this treatment option (7).
Among 21,059 patients from 236 sites in the GWTG Registry, 23% received predischarge ICD counseling. Women were counseled less frequently than men, and racial and
ethnic minorities were less likely to receive counseling than White patients (80).

1. ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with
LVEF of 35% or less and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival
for more than 1 year (81,82).† (Class 1, Level of Evidence: A)
†Counseling should be specific to each individual patient and should include documentation of a discussion about the potential for sudden death and non-sudden death from
HF or noncardiac conditions. Information should be provided about the efficacy, safety, and potential complications of an ICD and the potential for defibrillation to be
inactivated if desired in the future, notably when a patient is approaching end of life. This will facilitate shared decision-making among patients, families, and the medical care
team about ICDs (83).
2017 AHA/ACC/HRS ventricular arrhythmias and prevention of sudden cardiac death guideline (9)
1. Patients considering implantation of a new ICD or replacement of an existing ICD for a low battery should be informed of their individual risk of SCD and non-sudden death from HF or
noncardiac conditions and the effectiveness, safety, and potential complications of the ICD in light of their health goals, preferences, and values (84–88). (Class 1, Level of Evidence: B-
NR)
angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; DCM, dilated cardiomyopathy; EHR, electronic health record; GWTG, Get With The Guidelines; GDMT,
guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure reduced ejection fraction; HRS, Heart Rhythm Society; ICD, implantable cardioverter-defibrillator; LVAD, left
ventricular assist device; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association; PM, performance measure; and SCD, sudden cardiac death.
SHORTTITLE:PM-13
Cardiac Resynchronization Therapy Implantation for Patients With Heart Failure With Reduced Ejection Fraction on
Guideline-Directed Medical Therapy (Outpatient Setting)
PM-13: Cardiac Resynchronization Therapy Implantation for Patients With Heart Failure With Reduced Ejection Fraction on Guideline-Directed Medical Therapy (Outpatient
Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure with current LVEF #35%, LBBB, QRS duration $150 ms, NYHA class II, III, and IV,
despite ACE inhibitor, ARB, or ARNI and beta-blocker therapy for at least 3 mo who have undergone CRT implantation
Numerator Patients (meeting denominator criteria) who have undergone CRT implantation
Denominator All patients age $18 y with a diagnosis of heart failure with current LVEF #35%, LBBB, QRS duration $150 ms, NYHA class II, III,
and IV, despite ACE inhibitor, ARB, or ARNI and beta-blocker therapy for at least 3 mo

LVAD
Denominator Exceptions Documentation of medical reason(s) for not undergoing CRT implantation (e.g., multiple or significant comorbidities, limited life
expectancy)
Documentation of patient reason(s) for not undergoing CRT implantation (e.g., refusal)

Facility
Rationale
CRT has been shown to improve survival and symptoms among symptomatic patients with heart failure and LVEF #35%, LBBB, and QRS duration $150 ms ( 7). CRT
implantation (not just counseling) is recommended as CRT improves both quantity and quality of life, unlike ICDs, where there is no symptomatic benefit.
In the GWTG database from 2014, 26% of eligible patients had CRT in place, implanted, or prescribed (89). Women were less likely to receive CRT, and this disparity
increased over time. Black patients were less likely than White patients to have CRT.
1. CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, LBBB with a QRS duration of 150 ms or greater, and NYHA class II, III, or ambulatory IV
symptoms on GDMT. (Class 1, Level of Evidence: A for NYHA class III/IV (90–93); Level of Evidence: B for NYHA class II (94,95))
receptor–neprilysin inhibitor; CRT, cardiac resynchronization therapy; EHR, electronic health record; GWTG, Get With The Guidelines; GDMT, guideline-directed medical therapy; ICD,
implantable cardioverter-defibrillator; LBBB, left bundle branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; and PM,
performance measure.
Quality Measures for Heart Failure
SHORTTITLE:QM-1 Patient Self-Care Education (Outpatient Setting)
QM-1: Patient Self-Care Education (Outpatient Setting)
Measure Description: Percentage of patients age $18 y with a diagnosis of heart failure who were provided with self-care education during $1 visits within a 12-mo period
Numerator Patients who were provided with self-care education* during $1 visits within a 12-mo period
*Self-care education may include the following:

Definition of heart failure (linking disease, symptoms, and treatment) and cause of patient’s heart failure; recognition of escalating
symptoms and concrete plan for response to particular symptoms; indications and use of each medication; recommendations for
modification of risks for heart failure progression; specific diet recommendations; individualized low-sodium diet; recommendation
for alcohol intake; specific activity/exercise recommendations; importance of treatment adherence and behavioral strategies to
promote treatment adherence; importance of monitoring weight daily at home.
Denominator All patients age $18 y with a diagnosis of heart failure who were seen at least once for any visit within a 12-mo period

LVAD
Denominator Exceptions Documentation of medical reason(s) for not providing self-care education (e.g., comfort care only, dementia, or cognitive
impairment)
Documentation of patient reason(s) for not providing self-care education (e.g., patient refusal)


Facility
Rationale
Patient self-care education is a useful nonpharmacological component to heart failure care. It may reduce the likelihood of nonadherence with recommended therapeutic
strategies and lead to early identification of worsening clinical status and subsequent treatment. Heart failure disease management programs, in which patient education
is an integral component, have been shown to be effective in improving self-care and reducing readmissions (96). This measure is intended to highlight the importance of
providing appropriate self-care education to patients with heart failure. The form and manner of education (e.g., counseling, information in the form of pamphlets or
booklets) is at the discretion of the individual clinician and should be specific to the needs of the patient.
Data from the IMPROVE-HF registry indicate that only 61% of outpatients with heart failure were provided with education (including discussion of salt-restricted diet,
monitoring of daily weight, warning signs of worsened heart failure, and activity recommendations), with rates of adherence ranging from 0% to 100% among practices
(97).
A number of consensus groups/patient advocacy organizations have developed educational materials that are recommended to aid implementation of the measure.
These materials/tools include, but are not limited to:
n AHA’s Health Topics on Heart Failure. Available at: https://www.heart.org/en/health-topics/heart-failure (98) n ACC’s CardioSmart. Available at: https://www.cardiosmart.org/Heart-
Conditions/Heart-Failure (99)
n HFSA Education Modules on Heart Failure. Available at: https://learningcenter.hfsa.org/Public/Catalog/Home.aspx?Search¼heartþfailure&Criteria¼18 &tab¼2 (100)
n National Heart, Lung, and Blood Institute Heart Failure Information. Available at: https://www.nhlbi.nih.gov/health-topics/heart-failure (101)
n Heart Failure Association of the European Society of Cardiology. Available at: https://www.heartfailurematters.org/en_GB (102)

1. Patients with HF should receive specific education to facilitate HF self-care (103–108). (Class 1, Level of Evidence: B)
ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; HF, heart failure;
HFSA, Heart Failure Society of America; IMPROVE-HF, Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting; LVAD, left ventricular assist
device; and QM, quality measure.
SHORTTITLE:QM-2 Measurement of Patient-Reported Outcome-Health Status (Outpatient Setting)
QM-2: Measurement of Patient-Reported Outcome-Health Status (Outpatient Setting)
Measure description: Percentage of outpatients age $18 y with a diagnosis of heart failure who have a disease-specific patient-reported health status measurement
recorded within each 6-mo period
Numerator Patients with a disease-specific PRO reported in the medical record during a 6-mo period
Denominator All patients age $18 y with a diagnosis of heart failure

LVAD
Denominator Exceptions Documentation of medical reason(s) for not reporting a disease-specific, patient-reported health status measurement (e.g., severe
cognitive or functional impairment)
Documentation of patient reason(s) for not reporting a disease-specific, patient-reported health status measurement
Measurement Period 12 mo with at least 1 PRO reported in each 6 mo of the reporting cycle

Clinical registry

Facility

Rationale
A fundamental goal of treating patients with heart failure is to improve symptoms, which is most accurately quantified by directly asking them. Disease-specific PROs (e.g.,
MLHFQ or KCCQ) are recommended as they are more sensitive to clinical change in heart failure than general health status measures. PROs are also predictive of other
outcomes such as mortality, hospitalization, and costs (109–111) and often vary by sex, race/ethnicity, and socioeconomic status (112,113). Knowledge of a patient’s
reported health status may prompt changes in medications that will further improve care (114).
There are multiple disease-specific tools that have been developed to capture PROs in heart failure. The ACC/AHA have not addressed PRO tool selection. However, the
FDA has provided guidelines for an appropriate PRO tool (16) and, currently, 2 heart failure survey tools—the MLHFQ (15) and the KCCQ (14)—are considered qualified
tools for FDA device use in heart failure (17).
As a process measure for capturing a clinically important outcome, no risk-adjustment methods are required. It is required as a foundation for outcomes-based
performance measure and is paired with QM-3.
1. The ACC/AHA heart failure guideline modifies several recommendations based on the health status of the patient, usually quantified by the NYHA classi-fication (7).
ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; FDA, U. S. Food and
Drug Administration; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVAD, left ventricular assist device; MLHFQ, Minnesota Living with Heart Failure Questionnaire; NYHA, New York
Heart Association; PRO, patient-reported outcome; and QM, quality measure.
SHORTTITLE:QM-3 Sustained or Improved Health Status in Heart Failure (Outcome)
QM-3: Sustained or Improved Health Status (Patient-Reported Symptoms, Function, and Quality of Life) During the Reporting Period for All Patients With Heart Failure
Measure Description: Percentage of patients age $18 y with heart failure whose patient-reported outcome score does not decline significantly (a decrease in scores of $5
points for the KCCQ or an increase of $7 points for the MLHFQ*) during a 12-mo period
Numerator Patients whose last score within the past 6 mo of the reporting period is not significantly worse (did not decrease by $5 points for
the KCCQ or did not increase by $7 points for the MLHFQ*) than the first score in the first 6 mo of the reporting period
*A clinically significant change in PROMIS-PLUS-HF is not established at the time of this writing.
Denominator Heart failure patients age $18 y with at least 1 patient-reported outcome measurement in both the first and past 6 mo of the
measurement period (12 mo)

LVAD
Sources of Data Qualified EHR, QCDR, electronically or telephonically transmitted PROs

Facility
Rationale
Unlike the other measures in this measure set, this is an outcome comparable to mortality. Although using each patient as their own control minimizes some of the need for
risk adjustment, this measure has been designated as a quality metric because development of adequate risk-adjustment is needed prior to use as a performance
measure (accountability). Two of the disease-specific PROs (KCCQ and MLHFQ) have published thresholds for change that are considered clinically meaningful
(115,116). This outcome-based measure will enable comparison of the proportion of patients in each reporting unit that are not clinically worse over a year of treatment.
Given that patients are expected to decline over time, this measure is not expected to be near 100%.
1. Goals of treatment of heart failure preserved ejection fraction and heart failure reduced ejection fraction are to improve health-related quality of life and symptoms (Figure 3, 2013
ACCF/AHA guideline) (7).
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVAD,
left ventricular assist device; MLHFQ, Minnesota Living with Heart Failure Questionnaire; PRO, patient-reported outcome; PROMIS-PLUS-HF, Patient-Reported Outcomes Measure-ment
Information System-Plus-Heart Failure; QCDR, Qualified Clinical Data Registry; and QM, quality measure.
SHORTTITLE:QM-4 Postdischarge Appointment for Patients With Heart Failure (Inpatient Setting)
QM-4: Postdischarge Appointment for Patients With Heart Failure (Inpatient Setting)
Measure Description: Percentage of patients age $18 y discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of
heart failure for whom a follow-up appointment was scheduled within 7 d and documented before discharge (as specified)
Numerator Patients for whom a follow-up appointment was scheduled within 7 d and documented before discharge including either:
n An office visit (including location, date, and time) for management of heart failure n A home health visit (including location and date) for
management of heart failure n A telehealth visit (including location and date) for management of heart failure
Because of the nature of scheduling home health visits, the location and date of the follow-up appointment is sufficient for meeting the
measure.
Denominator All patients age $18 y discharged from an inpatient facility (e.g., hospital inpatient or observation) to ambulatory care (home or self-
care) or home health care with a principal discharge diagnosis of heart failure

LVAD
Denominator Exceptions Documentation of medical reason(s) for not documenting that a follow-up appointment was scheduled (e.g., patients transferring to
another facility)
Documentation of patient reason(s) for not documenting that a follow-up appointment was scheduled (e.g., patients who left against
medical advice or discontinued or transferred care)


Facility
Care Setting Inpatient
Rationale
An observational study found that early outpatient follow-up (within 7 d) after discharge from a heart failure hospitalization is associated with a lower risk of 30-d readmission
(117), although this has been an inconsistent finding (118). The writing committee agreed that more evidence is needed to support a short time period (<7 d) for the
postdischarge appointment before this metric becomes a performance measure.
1. Scheduling an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge are reasonable (117,119). (Class 2a, Level of
Evidence: B)
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; EHR, electronic health record; LVAD, left ventricular assist device; and QM, quality measure.
Structural Measure for Heart Failure
SHORTTITLE:SM-1 Heart Failure Registry Participation
SM-1: Participation in $1 Regional or National Registries That Include Patients With Heart Failure
Measure Description: Participation in a national or regional heart failure registry that provides regular performance reports based on benchmarked data
Numerator Does the facility participate in a national or regional heart failure registry* that provides regular performance reports based on
benchmarked data? (yes/no)
*Examples of such registries include the GWTG-HF, GWTG-360, PINNACLE Registry, and PINNACLE Registry Research Alliance.
Denominator Not applicable
Denominator Exclusions None
Measurement Period Not applicable
Sources of Data Facility attestation
Attribution Measure reportable at the facility level only

Inpatient
Rationale
Participation in a registry allows measurement of performance for heart failure care, including benchmarking against other facilities.
1. Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guideline–based quality and performance measures can be
beneficial in improving the quality of HF care (120,121). (Class 2a, Level of Evidence: B)
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; GWTG, Get With The Guidelines; HF, heart failure; PINNACLE, Practice Innovation And
Clinical Excellence; and SM, structural measure.
Rehabilitation Performance Measures Related to Heart Failure

(From the 2018 ACC/AHA performance measures for cardiac rehabilitation (6))
SHORTTITLE:PM-2 Exercise Training Referral for HFrEF From Inpatient Setting
PM-2: Exercise Training Referral for HFrEF From an Inpatient Setting
Measure Description: Percentage of patients, age $18 y, hospitalized with a primary diagnosis of HFrEF in the previous 12 mo, who are referred for outpatient exercise
training (or regular physical activity), typically delivered in the setting of an outpatient CR program
Numerator Patients hospitalized with primary diagnosis of HFrEF who have been referred to an outpatient CR program before hospital discharge
Referral is defined as:
1. Documented communication* between the healthcare provider and the patient to recommend an outpatient CR program
AND
2A. Official referral order† is sent to outpatient CR program
OR
2B. Documentation of patient refusal to justify why patient information was not sent to the CR program‡
Note: Performance is met if steps 1 AND either 2A (official referral order transmitted) OR 2B (patient refusal documented in the pa-
tient’s medical record) are completed and documented.
*All communications must maintain appropriate confidentiality as outlined by the Health Insurance Portability and Accountability Act
of 1996 (HIPAA).
†All patient information required for enrollment should be transmitted to the CR program. Necessary patient information may be found
in the hospital discharge summary.
‡Patients who refuse a CR referral should not have their data transmitted to the receiving CR program against their will.
Denominator All patients who have had HFrEF during the previous 12 mo, who are discharged from the hospital during the reporting period
Denominator Exclusions Patients age <18 y

Patients who leave during hospitalization against medical advice
Patients who die during hospitalization
Patients who are transferred to another hospital for inpatient care
Patients who are already participating in a CR program before hospitalization
Denominator Exceptions Documentation of a patient-oriented reason that precludes referral to CR (e.g., no traditional CR program available to the patient,
within 60 min [travel time] from the patient’s home, or patient does not have access to an alternative model of CR delivery that meets
all criteria for a CR program)
Documentation of a medical reason that precludes referral to CR (e.g., patient deemed by a medical provider to have a medically
unstable, life-threatening condition, or has other cognitive or physical impairments that preclude CR participation)
Documentation of a healthcare system reason that precludes referral to CR (e.g., patient is discharged to a nursing care or long-term
care facility, or patient lacks medical coverage for CR)
Measurement Period Encounter
Sources of Data Medical record or other database (e.g., administrative, clinical, registry)
Attribution Measure reportable at facility level
Care Setting Inpatient
Rationale
Exercise training services have been shown to improve functional status and may help reduce morbidity and mortality in persons with stable chronic heart failure with reduced
HFrEF. However, these services are used in a minority of eligible patients (122,123).
A key component to outpatient exercise training (typically carried out in a CR program) is the appropriate and timely referral of patients. Generally, the most important time for
this referral to take place is while the patient is hospitalized for a HFrEF.
This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize the appropriate referral of a
patient to an outpatient exercise training program.
This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve patients with HFrEF.
This performance measure is provided in a format that allows for easy and flexible inclusion into such performance measurement sets.
Effective referral of appropriate inpatients to an outpatient exercise training program is the responsibility of the healthcare team within a healthcare system that is primarily
responsible for providing cardiovascular care to the patient with HFrEF during hospitalization.
Published evidence suggests that automatic referral systems, accompanied by strong and supportive advice and guidance from a healthcare professional, can
significantly help improve CR referral and enrollment, where exercise training typically takes place for patients with HFrEF.
1. Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status (124–130).
(Class 1, Level of Evidence: A)
2011 AHA prevention of cardiovascular disease in women guideline update (131)
1. A comprehensive CVD risk-reduction regimen such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program
should be recommended to women with a recent acute coronary syndrome or coronary revascularization, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial
disease (Class 1; Level of Evidence A) or current/prior symptoms of heart failure, and an LVEF #35%. (Class 1; Level of Evidence B)
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; CR, cardiac rehabilitation; CVD, cardiovascular disease; HF, heart failure; HFrEF, heart
failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; and PM, performance measure.
SHORTTITLE:PM-4 Exercise Training Referral for HFrEF From Outpatient Setting
PM-4: Exercise Training Referral for HFrEF From an Outpatient Setting
Measure Description: Percentage of patients, age $18 y, evaluated in an outpatient setting who, within the previous 12 mo, have had a new HFrEF event or exacerbation and
have not participated in an exercise training program, such as provided in CR programs, for the qualifying event/diagnosis, are to be referred for exercise training.
Numerator Patients in an outpatient clinical practice who have had a new HFrEF event or exacerbation and have not participated in a supervised
exercise training program (e.g., as a CR program) during the previous 12 mo, who have been referred to an outpatient CR program
Referral is defined as:
1. Documented communication* between the healthcare provider and the patient to recommend an outpatient CR program
AND
2A. Official referral order† is sent to outpatient CR program
OR
2B. Documentation of patient refusal to justify why patient information was not sent to the CR program‡
Note: Performance is met if steps 1 AND either 2A (official referral order transmitted) OR 2B (patient refusal documented in the
patient’s medical record) are completed and documented.
*All communications must maintain appropriate confidentiality as outlined by the Health Insurance Portability and Accountability Act
of 1996 (HIPAA).
†All patient information required for enrollment should be transmitted to the CR program. Necessary patient information may be
found in the hospital discharge summary.
‡Patients who refuse a CR referral should not have their data transmitted to the receiving CR program against their will.
Denominator All patients in an outpatient clinical practice who have had HFrEF during the previous 12 mo
Denominator Exclusions Patients age <18 y

Patients who leave clinic visit against medical advice
Patients have already participated in or had already completed a CR program prior to clinic visit
Denominator Exceptions Documentation of a patient-oriented reason that precludes referral to CR (e.g., no traditional CR program available to the patient,
within 60 min [travel time] from the patient’s home, or patient does not have access to an alternative model of CR delivery that
meets all criteria for a CR program)
Documentation of a medical reason that precludes referral to CR (e.g., patient deemed by a medical provider to have a medically
unstable, life-threatening condition, or has other cognitive or physical impairments that preclude CR participation)
Documentation of a healthcare system reason that precludes referral to CR (e.g., patient resides in a nursing care or long-term care
facility, or patient lacks medical coverage for CR)
Measurement Period Encounter
Sources of Data Medical record or other database (e.g., administrative, clinical, registry)
Attribution Measure reportable at provider and facility level
Rationale
CR services have been shown to help improve functional status and may help reduce morbidity and mortality in persons with stable chronic heart failure with reduced HFrEF.
However, these services are used in a minority of eligible patients (122,123).
A key component to outpatient CR program utilization is the appropriate and timely referral of patients. Generally, the most important time for this referral to take place is while
the patient is hospitalized for a HFrEF.
This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize the appropriate referral of a
patient to an outpatient CR program.
This measure is designed to serve as a stand-alone measure or, preferably, to be included within other performance measurement sets that involve patients with HFrEF.
This performance measure is provided in a format that allows for easy and flexible inclusion into such performance measurement sets.
Effective referral of appropriate inpatients to an outpatient CR program is the responsibility of the healthcare team within a healthcare system that is primarily
responsible for providing cardiovascular care to the patient with HFrEF during hospitalization.
Published evidence suggests that automatic referral systems accompanied by strong and supportive advice and guidance from a healthcare professional can significantly
help improve CR referral and enrollment.
1. Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status (124–130). (Class 1,
Level of Evidence: A)
2011 AHA prevention of cardiovascular disease in women guideline update (131)
1. A comprehensive CVD risk-reduction regimen such as cardiovascular or stroke rehabilitation or a physician-guided home- or community-based exercise training program should be
recommended to women with a recent acute coronary syndrome or coronary revascularization, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease
(Class 1; Level of Evidence A) or current/prior symptoms of heart failure and an LVEF #35%. (Class 1; Level of Evidence B)
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; CR, cardiac rehabilitation; CVD, cardiovascular disease; HF, heart failure; HFrEF, heart
failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; and PM, performance measure.
256
HFACC/AHA2020
APPENDIX B. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)—2020 ACC/AHA
.aletHeidenreich Measures
CLINICAL PERFORMANCE AND QUALITY MEASURES FOR HEART FAILURE
Institutional,
Organizational,
or Other
Speakers Ownership/Partnership/ Personal Financial Expert
Committee Member Employment Consultant Bureau Principal Research Benefit Witness
Paul A. Heidenreich Stanford VA Palo Alto Health
(Chair) Care None None None None None None
System—Professor of
Medicine
Gregg C. Fonarow* UCLA Medical Center—
(Vice Chair) Professor of n Abbott† None None n Medtronic n Boston Scientific None
Medicine n Amgen n Novartis†
n Astra
Zeneca
n CHF Solutions
n Janssen
Pharmaceuticals
n Medtronic
n Merck
n Novartis†
UA College of Medicine,
Khadijah Breathett‡ Tucson— None None None None None None
Assistant Professor of
Medicine
Boston College, School of
Corrine Y. Jurgens Nursing— None None None None None None
Associate Professor
Wake Forest Baptist Medical
Barbara A. Pisani* Center— None None None None n Abbott§ None
Medical Director, Heart n Amgen—GALACTIC HF
Failure, Heart Trial (PI)
Transplant, Mechanical
Circulatory n Medtronic§
Novartis—PIONEER Trial
Support n (PI)
nSanofi-Aventis—
SOLOIST Study
(PI)
University of Nebraska
Bunny J. Pozehl Medical Center, None None None None None None
Omaha Division—Professor
College of
Nursing
Saint Luke’s Mid America
John A. Spertus* Heart n Amgen None None None n Abbott None
Institute—Director, Health
Outcomes n AstraZeneca† n AstraZeneca UK Limited
Research; University of
Missouri- n Bayer n Outcomes Instruments†
Boehringer
Kansas City—Professor n Ingelheim† n Medtronic
n Janssen n Novartis†
Pharmaceuticals†
n KCCQ†
n Merck†
n Novartis†
Piedmont Heart Institute—
Kenneth G. Taylork Heart None None None None None None
Failure and Interventional
Cardiologist
Continued on the next page

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APPENDIX B. CONTINUED
EVON EBM
CCAJ LOV
Institutional,
Organizational,
,42
,67
or Other
Speakers Ownership/Partnership/ Personal Financial Expert
.ON ,12 02 0
202 2:0 725 6- 4
Committee Member Employment Consultant Bureau Principal Research Benefit Witness
Jennifer T.
Thibodeau* University of Texas Southwestern None None None n Novartis None None
Medical Center—Associate
Professor;
Director, Heart Failure; Interim
Section
Chief, Heart Failure, Cardiac
Transplantation, Ventricular Assist
Devices
Clyde W. Yancy Northwestern University, Feinberg None None None None n Abbott§ None
School of Medicine—Magerstadt
Professor of Medicine; Division of
Cardiology—Chief
Boback Ziaeian UCLA David Geffen School of None None None None None None
Medicine—Assistant Professor; VA
Greater Los Angeles Healthcare
System—Director of Telecardiology
This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed
and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect
relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of $5% of the voting stock or
share of the business entity, or ownership of $$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the
person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest
unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual
property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the
document or makes a competing drug or device addressed in the document; or c) the person, or a member of the person’s household, has a reasonable potential for financial,
professional, or other personal gain or loss as a result of the issues/content addressed in the document.
*Writing committee members were excluded from voting on sections to which their specific relationships with industry and other entities may apply. Dr. Fonarow was excluded from voting
on PM-4, PM-5, PM-6, PM-7, PM-8, PM-9, PM-10, PM-12, PM-13,
and SM-1. Dr. Pisani was excluded from voting on PM-5, PM-6, PM-8, PM-12, and PM-13. Dr. Spertus was excluded from voting on PM-2, PM-3, PM-4, PM-5, PM-6, PM-7, PM-8, PM-9,
PM-10, PM-12, PM-13, QM-2, QM-3, and SM-1. Dr. Thibodeau was
excluded from voting on PM-5, PM-6, and PM-8.
†Significant relationship.
‡CMS reported payments to Dr. Breathett in 2019 related to food, beverage, travel, and lodging for Abbott; however, she disagrees with this report. Dr. Breathett was not the lead author
on any measures.
§No financial benefit.
kCMS reported a food and beverage payment from Novartis to Dr. Taylor in 2019, however, he disagrees with this report. Novartis has marked the food and beverage entry for deletion.
Dr. Taylor was not the lead author on any measures.
ACC indicates American College of Cardiology; AHA, American Heart Association; HF, heart failure; KCCQ, Kansas City Cardiomyopathy Questionnaire; PI, principal investigator;
UA, University of Arizona; UCLA, University of California, Los Angeles; UK, United Kingdom; and VA, Veterans Affairs.
MeasuresHFACC/AHA2020
.aletHeidenreich
OO
wr
ng
APPENDIX C. REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (COMPREHENSIVE)—2020 ea
ACC/AHA CLINICAL PERFORMANCE AND QUALITY MEASURES FOR HEART FAILURE rn
si
hz
ia
Institutional,
pt
/ ional, or
256
Speaker
s Partnership/ Other Financial
Representati Personal
Reviewer on Employment Consultant Bureau Principal Research Benefit Expert Witness
Siqin Kye ACC/AHA Center for Behavioral
HFACC/AHA2020
Ye TFPM Cardiovascular None None None None None None
Lead Health—Assistant Professor of
Reviewer Medicine;
Cardiology Inpatient
Consultation Service—
Director; Columbia Doctors—
Associate
Chief Medical Officer
University of Tennessee Health
John L. Official ACC Science n Abbott* n Ambry None None None None
Jefferie Center—Jay M. Sullivan Genetic
s Distinguished Chair n Amicus s
in Cardiovascular Medicine,
Chief of n AstraZeneca n Pfizer
Cardiology n Bayer* n Sanofi
CHF Genzy
n Solutions* me*
n Medtronic*
n Myokardia
n Protalix
n Sanofi
Genzyme*
n Stealth
Biotherapeut
ics
Pam University of Colorado Anschutz
Peterson Official ACC Medical n AHA* None None n NHLBI† None None
Campus—Professor of
Medicine, Denver
Health Medical Center
Penn State College of Medicine
Howard J. Official AHA —Chief, None None None None None None
Eisen Division of Cardiology
Washington University School of
Janet N. Official AHA Medicine/ None None None None None None
St. Louis Children’s Hospital—
Scheel Professor of
Pediatrics and Pediatric
Cardiologist
Robert Duke University School of
John Official HFSA Medicine— n Abbott None None n American Regent† None None
Associate Professor of Medicine,
Mentz Associate n Akros n Amgen†
Professor in Population Health
Sciences, n Amgen* n AstraZeneca†
Member in the Duke Clinical
Research n Bayer* n Bayer†
Institute n Boehringer n Bristol-Myers Squibb†
Ingelheim* n Gilead Sciences†
n HeartWare n GlaxoSmithKline†
Luitpold
n Janssen n Pharmaceuticals†
n Luitpold n Medtronic†
Pharmaceuti
cals n Merck†
n Merck* n Novartis†
Otsuka Pharmaceutical
n Novartis* n Co.†
Sanofi-
n Aventis* n Resmed†
n Thoratec n Vifor
Mary St. Vincent Heart Center of
Norine Content ACC Indiana— None None None None n EBR Systems None
Medical Director Heart Failure
Walsh and Cardiac n Thoratec‡
Transplantation n Uppsala
University‡
Continued on the
next page
MEVON REB
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67
,
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.ON
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52:
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02
02
46
APPENDIX C. CONTINUED o
f
Institutional, P
Organizational, h
Ownership/ or a
Speaker Other r
s Partnership/ Financial m
Representati Personal a
Reviewer on Employment Consultant Bureau Principal Research Benefit Expert Witness c
Eldrin F. Brigham and Women’s Hospital Defendant, y
Lewis Content AHA —Associate n Amgen† None None n Amgen* None n Sudden ,
Physician; Harvard Medical
School— n DalCor* n Merck* death, 2019
Associate Professor of Medicine n Novartis* R
n NIH (NHLBI)*
e
n Novartis*
s
Content Research and Innovation, Novarti e
Nancy M. ACC/ Cleveland Clinic n AstraZeneca n s None n Novartis† n HFSA† None a
Health System & CNS/Kaufman r
Albert AHA Center for n Boston c
Heart Failure, Heart, Vascular & h
Thoracic Scientific†
Institute—Associate Chief
Nursing Officer n Novartis P
r
Sana M. Content Duke University School of Plaintiff, patient o
Al- ACC/ Medicine— n Medtronic None None n Abbott n Abbott n died
f
Professor of Medicine, Member in eN
Khatib AHA the Duke n Milestone n FDA* n AHA* of VT due to QT- so
Pharmaceuti prolonging sv
Clinical Research Institute cals n Medtronic n Bristol-Myers meds, oa
n NHLBI* Squibb 2018 rr
Plaintiff, SCD, t
n PCORI* n Medtronic n 2018 i
Plaintiff, SCD os
n Pfizer n Preven- f†
tion, 2018 M
e
Anita Content Baylor College of Medicine—
d
Deswal ACC/ Chief, None None None n NIH* n ACC/AHA None
i
Medicine-Cardiology, Michael E.
c
AHA DeBakey n HFSA†
i
VA Medical Center & Baylor
n
College of
e
Medicine; Professor, Medicine-
Cardiology,
Winters Center for Heart Failure
Research Continued on the
Mona Content Duke University School of

Fiuzat ACC/ Medicine— None None None n Roche* None None
Adjunct Associate Professor,
AHA Department
of Medicine
Content Duke University School of Defendant,
Adrian F. ACC/ Medicine—Vice n Amgen None None n American Regent n AHA† n patent
Hernan
dez AHA Dean for Clinical Research n AstraZeneca n AstraZeneca* dispute, 2019
n Bayer n Daiichi Sankyo
n BioFourmis n Eidos (DSMB)
n Boehringer n Genentech
Ingelheim n GlaxoSmithKline*
Luitpold
n Boston n Pharmaceuticals
Scientific* n NIH†
n Merck n Merck
n Novartis* n Novartis*
n Pfizer n PCORI†
n Relypsa n Verily*
Sanofi-
n Aventis
n Xogenex
Content UNC Eshelman School of
J. Herb ACC/ Pharmacy— n Novartis* None None n Amgen† None None
Patters Interim Chair, Division of
on AHA Pharmacotherapy n Boehringer Ingelheim†
and Experimental Therapeutics,
Professor n Merck†
EVON EBM
CCAJ LOV
,42
,67
.ON ,12
202 2:0 725 6- 4
02 2
0
MeasuresHFACC/AHA2020
.aletHeidenreich
256
APPENDIX C. CONTINUED
HFACC/AHA2020
Institutional,
Organizational,
Ownership/ or
Speakers Partnership/ Other Financial
Representati
Reviewer on Employment Consultant Bureau Principal Personal Research Benefit Expert Witness
Andrea Cooper Medical School of
Russo Content ACC/ Rowan None None None None n Apple† None
University—Professor of
AHA Medicine and n Boehringer
Director; Cardiac
Electrophysiology and Ingelheim‡
Boston
Arrhythmia Services—Director; n Scientific†‡
Cardiovascular Research
Cooper University n Kaestra‡
Hospital Dorrance #393—
Program n MediLynx‡
Director, Clinical Cardiac
Electrophysiology n UpToDate
Fellowship
Paul nResearch Grant Funding: PI
Varosy Content ACC/ VA Eastern None None None Career n AHA† None
A
H
A Colorado Health Development Award, Co-
Care System— Investigator VA Merit Review Grant*
Director of Cardiac
Electrophysiology
This table represents all relationships of reviewers with industry and other entities that were reported at the time of peer review, including those not deemed to be relevant to this
document, at the time this document was under review. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a
significant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 of the fair market value of the
business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial
benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of
review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories or additional
information about the ACC/AHA Disclosure Policy for Writing Committees. *Significant (greater than $5,000) relationship.
†No financial relationship.

‡This disclosure was entered under the Clinical Trial Enroller category in the ACC’s disclosure system.
ACC indicates American College of Cardiology; AHA, American Heart Association; CNS, Clinical Nurse Specialist; DSMB, Data Safety and Monitoring Board; FDA, U. S. Food and
Drug Administration; HFSA, Heart Failure Society of America; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; PCORI, Patient-Centered Outcomes
Research Institute; PI, principal investigator; SCD, sudden cardiac death; TFPM, Task Force on Performance Measures; UNC, University of North Carolina; VA, Veterans
Administration; and VT, ventricular tachycardia.
CCAJ LOV . 67 , .ON ,12 02 02
MEVON REB ,42 0202 52: -72 46

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 76, NO.

2020 ACC/AHA Clinical Performance

Developed in Collaboration With the Heart Failure Society of America

Members Clyde W. Yancy, MD, MSC, MACC, FAHA, FHFSA

2020 ACC/AHA HF Measures NOVEMBER 24, 2020:25 27-64

Force on Jeffrey W. Olin, DO, FACC, FAHAx

Patricia A. Keegan, DNP, APRN, NP-C xAmerican Heart Association Representative.

Short Title: PM-1: Left

1.1. Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . 2533

1.2. Disclosure of Relationships With Industry and

2.1. Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . 2533

2.2. Definition and Selection of Measures . . . . . . . . . 2534

3. ACC/AHA HEART FAILURE MEASURE SET . . . . . . 2534

3.1. Discussion of Changes to 2011 Heart Failure

3.1.1. Retired Measures . . . . . . . . . . . . . . . . . . . . 2534

4. AREAS FOR FURTHER RESEARCH . . . . . . . . . . . . . 2535

Heart Failure Measure Set . . . . . . . . . . . . . . . . . . . . . . 2539

(Outpatient Setting) . . . . . . . . . . . . . . . . . . . . 2547 Short Title: PM-9: Mineralocorticoid

Writing committees are instructed to consider the methodology of

2020 ACC/AHA HF Measures NOVEMBER 24, 2020:25 27-64

Rehabilitation Performance Measures Related to Heart Failure

2020 ACC/AHA HF Measures NOVEMBER 24, 2020:25 27-64

The writing committee developed a comprehensive heart failure

Reliability c) The measure is reproducible across organizations and delivery settings.

Face validity d) The measure appears to assess what it is intended to.

Content validity e) The measure captures most meaningful aspects of care.

will be used to determine if a contraindication exists. For example,

can be individualized. It is not expected that all measures will be adopted

that involves patient input, it is important to consider the patient’s health

2020 ACC/AHA HF Measures NOVEMBER 24, 2020:25 27-64

T A B L E 7 New Heart Failure Measures

Measure Rationale for Creating Rationale for Designating as a Quality

2.2. Definition and Selection of Measures 3.1.1. Retired Measures

3.1.2. Revised Measures

guideline for the management of heart failure: a report of

and the Heart Failure Society of America. J Am Coll Cardiol.

8. Ponikowski P, Voors AA, Anker SD, et al.

9. Al-Khatib SM, Stevenson WG, Ackerman

2020 ACC/AHA HF Measures NOVEMBER 24, 2020:25 27-64

comparison between patients with heart failure and

42. Konstam MA, Neaton JD, Dickstein K, et

43. Pfeffer MA, McMurray JJV, Velazquez

44. Pfeffer MA, Swedberg K, Granger CB, et

45. McMurray JJV, Packer M, Desai AS, et

46. Group CTS. Effects of enalapril on

47. Yusuf S, Pitt B, Davis CE, et al. Effect of

48. Effect of ramipril on mortality and

49. Køber L, Torp-Pedersen C, Carlsen JE, et al.

A clinical trial of the angiotensin-converting–enzyme

50. Packer M, Poole-Wilson P, Armstrong P,

51. Pfeffer MA, Braunwald E, Moyé LA, et al.

66. Greene SJ, Fonarow GC, DeVore AD, et al.

et al. Clin-ical outcomes in patients with acute June 24, 2020.

2017;19:904–14. ferences in response to therapy for heart failure: analysis of the

Relationship of beta-blocker dose with outcomes in race/ethnicity differences in implantable cardioverter-defibrillator

99. American College of Cardiology. CardioSmart heart

2014;7:243–60. Available at: https://learningcenter.hfsa.org/Public/

87. Stewart GC, Weintraub JR, Pratibhu PP,

88. Yuhas J, Mattocks K, Gravelin L, et al.