Coronary Artery Disease (CAD): Beta-Blocker Therapy–Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)

Nonadherence to cardioprotective medications is prevalent among outpatients with CAD and can be associated with a broad range of adverse outcomes, including all-cause and cardiovascular mortality, cardiovascular hospitalizations, and the need for revascularization procedures (Gibbons et al., 2002).

This measure is intended to promote beta-blocker usage in select patients with CAD.

Beta-blocker therapy should be used in all patients with LV systolic dysfunction (EF <= 40%) with heart failure or prior MI, unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce risk of death.) (Class I, Level of Evidence: A) (Fihn et al., 2012).

In patients with chronic coronary disease (CCD) and LVEF ≤40% with or without previous MI, the use of beta-blocker therapy is recommended to reduce the risk of future Major Adverse Cardiac Events (MACE), including cardiovascular death. (Class 1, Level of Evidence: A) (Virani et al., 2023)

Prior Myocardial Infarction (MI) for denominator 2 is limited to those occurring within the past 3 years.

LVEF <= 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction (LVSD). The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram:

1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.

– For patients with prior MI, beta-blocker therapy includes any agent within the beta-blocker drug class. As of 2015, no recommendations or evidence are cited in current stable ischemic heart disease guidelines for preferential use of specific agents.

– For patients with prior LVEF <=40%, beta-blocker therapy includes the following: bisoprolol, carvedilol, or sustained release metoprolol succinate.

The requirement of two or more visits is to establish that the eligible clinician has an existing relationship with the patient.

A range value should satisfy the logic requirement for ‘Ejection Fraction’ as long as the ranged observation value clearly meets the less than or equal to 40% threshold noted in the denominator logic. A range that is greater than 40% would not meet the measure requirement.

In order for the Ejection Fraction result pathway to be recognized as below 40%, the result must be reported as a number with unit of %. A text string of “below 40%” or “ejection fraction between 35 and 40%” will not be recognized through electronic data capture. Although, this criteria can also be met using the Diagnosis pathway if specified as “Moderate or Severe.”

If a patient has had a myocardial infarction (MI) within the past 3 years and a current or prior LVEF <=40% (or moderate or severe LVSD), the patient should only be counted in Population Criteria 1.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons).