ACC/AHA Update Performance, Quality Measures for HF Care

The American College of Cardiology and the American Heart Association (ACC/AHA) have provided an update to their clinical performance and quality measures for adults with heart failure (HF) to bring them in line with the latest guidelines.

“The principle behind these [types of] documents in general is to create measures that are based on evidence that can be useful for clinicians and healthcare organizations to really improve outcomes for their patients,” Michelle Kittleson, MD, PhD (Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA), chair of the writing committee, explained to TCTMD.

Three new performance measures, which are based on the strongest recommendations (Class 1 and 3) from the 2022 iteration of the US heart failure guideline, address optimal blood pressure control in patients who have heart failure with preserved ejection fraction (HFpEF), use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with reduced ejection fraction (HFrEF), and initiation of guideline-directed medical therapy (GDMT) in hospitalized patients.

The document, published online Thursday in the Journal of the American College of Cardiology and Circulation: Cardiovascular Quality and Outcomes, also contains six new quality measures, which are based on evidence that is not as strong as that backing the performance measures.

The performance measures “can be used for public reporting or pay-for-performance programs,” Kittleson said. She and her colleagues note that the quality measures, on the other hand, “generally comprise metrics that might be useful for clinicians and healthcare organizations for quality improvement” but shouldn’t be used for those other purposes.

A Focus on Appropriate Medical Therapy

Most of the new performance and quality measures in the document, which updates a prior 2020 version, are centered around getting patients on the appropriate medical therapy.

One performance measure focuses on the initiation of four-pillar GDMT—which includes use of a renin-angiotensin-aldosterone system (RAAS) inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGTL2 inhibitors—at the time of discharge following a hospitalization for HF. Another addresses use of SGLT2 inhibitors for patients with symptomatic HFrEF in either the inpatient or outpatient setting.

“SGLT2 inhibitors, of course, burst onto the scene in the last 5 years,” Kittleson said. “It's really becoming a cornerstone of care for patients with heart failure across the spectrum of ejection fraction.”

The three performance measures are rounded out by one looking at the proportion of patients with HFpEF who have optimal control of hypertension, which “we know . . . will help these patients feel better and potentially stay out of the hospital, optimize their heart function,” Kittleson said.

Half of the six quality measures also involve appropriate use of medical therapy:

• Use of SGLT2 inhibitors for patients with HF and either mildly reduced or preserved EF (based on the results of the EMPEROR-Preserved and DELIVER trials)
• Continuation of GDMT for patients with HF and an improved EF to prevent a relapse of cardiomyopathy and reduced LVEF
• Optimization of GDMT prior to transcatheter edge-to-edge repair (TEER) for chronic secondary severe mitral regurgitation (MR) in patients with HFrEF

“The COAPT trial, of course, received great fanfare in that patients after optimization with persistent severe MR had better outcomes [after TEER], but it's so important to emphasize that point: heart failure therapy should first be optimized,” Kittleson said.

Three additional quality measures cover screening for and taking action on social determinants of health; counseling on use of contraception and on cardiovascular risks during pregnancy for patients with cardiomyopathy; and performance of a monoclonal protein screen in patients who have undergone bone scintigraphy for suspected cardiac amyloidosis.

“There's so much wealth in the heart failure guidelines, there's over a hundred recommendations, but [we chose] to highlight those we felt were the most pivotal and important for clinicians and healthcare organizations alike to incorporate into care,” Kittleson said.

Although these documents are often used in public reporting and pay-for-performance programs, the hope is that they also will be used by clinicians in their day-to-day practice, she added. “It comes down to an emphasis on the importance of implementation on an individual patient level, but also on an organizational level.”

These updated measures were developed in collaboration with the Heart Failure Society of America and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Society of Health-System Pharmacists, the Heart Rhythm Society, and the International Society for Heart and Lung Transplantation.