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 *Prescribed may include: 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. 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 women (or estimated glomerular filtration rate >30 mL/min/1.73 m2) and K <5.0 mEq/L
Denominator Exclusions	Heart transplant LVAD
Denominator Exceptions	Documentation of medical reason(s) for not prescribing MRA therapy Documentation of patient reason(s) for not prescribing MRA therapy
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 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).
Clinical Recommendation(s)
2013 ACCF/AHA heart failure clinical practice guideline (7) 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 mL/min/1.73 m2), 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.