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
Denominator Exclusions	Heart transplant 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
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
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).
Clinical Recommendation(s)
2017 ACC/AHA/HFSA heart failure guideline update (4) 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).

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; 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.