Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.
Last updated: January 15, 2026
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Estimate only — actual CMS scoring may vary based on reporting method, data completeness, and annual rule updates.
📖Clinical Rationale
Use of ACE inhibitor, ARB, or ARNI therapy has been associated with improved outcomes in patients with reduced LVEF. Long-term therapy with ARBs have also been shown to reduce morbidity and mortality, especially in ACE inhibitor– intolerant patients. More recently, ARNI therapy has also been shown to more significantly improve outcomes, such that the newest guidelines recommend replacement of ACE inhibitors or ARBs with ARNI therapy in eligible patients.
However, despite the benefits of these drugs, use of ACE inhibitor, ARB, or ARNI remains suboptimal.
📝Clinical Recommendations
In patients with HFrEF and NYHA class II to III symptoms, the use of ARNi is recommended to reduce morbidity and mortality. (Class 1, Level of Evidence A) (AHA/ACC/HFSA, 2022) In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible. (Class 1, Level of Evidence A) (AHA/ACC/HFSA, 2022) In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNi is not feasible, the use of ARB is recommended to reduce morbidity and mortality (Class 1, Level of Evidence A) (AHA/ACC/HFSA, 2022) In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or ARB, replacement by an ARNi is recommended to further reduce morbidity and mortality.
(Class 1, Level of Evidence B-R) (AHA/ACC/HFSA, 2022) ARNi should not be administered concomitantly with ACEi or within 36 hours of the last dose of an ACEi. (Class 3: Harm, Level of Evidence B-R) (AHA/ACC/HFSA, 2022) ARNi should not be administered to patients with any history of angioedema. (Class 3: Harm, Level of Evidence C-LD) (AHA/ACC/HFSA, 2022) ACEi should not be administered to patients with any history of angioedema.
(Class 3: Harm, Level of Evidence C- LD) (AHA/ACC/HFSA, 2022) Drugs Commonly Used for Stage C HFrEF (abbreviated to align with focus of measure to include only ACE inhibitors, ARB, and ARNI therapy) Table 1 - Drugs Commonly Used for Stage C HFrEF. Rows 3 - 10 define ACE Inhibitors. Rows 12-14 define ARB Therapy. Row 16 define ARNI. Drug Initial Daily Dose(s) Target Dose(s) Mean Doses Achieved in Clinical Trials ACE Inhibitors Captopril 6.
25 mg 3 times 50 mg 3 times 122.7 mg total daily Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg total daily Fosinopril 5 to 10 mg once 40 mg once N/A Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg total daily Perindopril 2 mg once 8 to 16 mg once N/A Quinapril 5 mg twice 20 mg twice N/A Ramipril 1.25 to 2.5 mg once 10 mg once N/A Trandolapril 1 mg once 4 mg once N/A Angiotensin Receptor Blockers Candesartan 4 to 8 mg once 32 mg once 24 mg total daily Losartan 25 to 50 mg once 50 to 150 mg once 129 mg total daily Valsartan 20 to 40 mg once 160 mg twice 254 mg total daily ARNI Sacubitril/valsartan 49/51 mg twice (sacubitril/valsartan) (therapy may be initiated at 24/26 mg twice) 97/103 mg twice (sacubitril/valsartan) 182/193 mg (sacubitril/valsartan) total daily For the hospitalized patient: In patients with HFrEF requiring hospitalization, preexisting GDMT* should be continued and optimized to improve outcomes, unless contraindicated.
(Class 1, Level of Evidence B-NR) (AHA/ACC/HFSA, 2022) In patients with HFrEF, GDMT should be initiated during hospitalization after clinical stability is achieved (Class 1, Level of Evidence B-NR) (AHA/ACC/HFSA, 2022) In patients with HFrEF, if discontinuation of GDMT is necessary during hospitalization, it should be reinitiated and further optimized as soon as possible.
📋Implementation Notes
This measure contains two strata defined by two submission criteria. This measure produces a single performance rate using a weighted average. There are 2 Submission Criteria for this measure: 1) All patients with a diagnosis of HF assessed during an outpatient encounter OR 2) All patients with a diagnosis of HF and discharged from hospital Both submission criteria should be submitted as appropriate.
For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once. Only patients who had at least two denominator eligible visits during the performance period will be counted for Submission Criteria 1.
When submitting CPT code 99238 and 99239, it is recommended the measure be submitted each time the code is submitted for hospital discharge.
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