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 *Prescribed may include: 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. Inpatient setting: Prescription given to the patient for hydralazine/isosorbide dinitrate therapy at discharge or hydralazine/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
Denominator Exclusions	Heart transplant 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
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
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).
Clinical Recommendation(s)
2013 ACCF/AHA heart failure clinical practice guideline (7) 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)

ACCF indicates 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; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; and PM, performance measure.