Home » Contraindication to Both ACEI and ARB at Discharge
Print this page

Release Notes:
Data Element
Version 2010A1

Data Element Name: Contraindication to Both ACEI and ARB at Discharge
Collected For: AMI-3, HF-3,
Definition:Contraindications/reasons for not prescribing either angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) include: (1) ACEI allergy AND ARB allergy, (2) moderate or severe aortic stenosis, (3) physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist documentation of BOTH a reason for not prescribing ACEI at discharge AND a reason for not prescribing an ARB at discharge**, (4) reason documented by physician/APN/PA or pharmacist for not prescribing an ARB at discharge AND an ACEI allergy, or (5) reason documented by physician/APN/PA or pharmacist for not prescribing an ACEI at discharge AND an ARB allergy. ACEIs and ARBs widen or dilate blood vessels, lowering blood pressure and making it easier for the heart to pump blood. They also inhibit the adverse effects of neurohormonal activation on the heart. These effects help reduce the risk of adverse outcomes such as death or hospitalization.
Suggested Data Collection Question:Is BOTH a potential contraindication/reason for not prescribing an angiotensin converting enzyme inhibitor (ACEI) at discharge AND a potential contraindication/reason for not prescribing an angiotensin receptor blocker (ARB) at discharge documented?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   Documentation that the patient has BOTH a potential contraindication/reason for not prescribing an ACEI at discharge AND a potential contraindication/reason for not prescribing an ARB at discharge, as evidenced by one or more of the following:

  • ACEI allergy AND ARB allergy
  • Moderate or severe aortic stenosis (This is a contraindication to both ACEIs and ARBs)
  • Physician/APN/PA or pharmacist documentation of BOTH a reason for not prescribing ACEI at discharge AND a reason for not prescribing an ARB at discharge. * *Note: Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions only:
    • Angioedema
    • Hyperkalemia
    • Hypotension
    • Renal artery stenosis
    • Worsening renal function/renal disease/dysfunction
  • Reason documented by physician/APN/PA or pharmacist for not prescribing an ARB at discharge AND an ACEI allergy
  • Reason documented by physician/APN/PA or pharmacist for not prescribing an ACEI at discharge AND an ARB allergy

N   (No)   There is no documentation of BOTH a potential contraindication/reason for not prescribing an ACEI at discharge AND a potential contraindication/reason for not prescribing an ARB at discharge, or unable to determine from medical record documentation.

Notes for Abstraction:
  • This data element should be answered independently and irrespective of whether the patient was prescribed ACEI and/or ARB at discharge.
  • When there is documentation of an “allergy” or “sensitivity,” regard this as documentation of an allergy regardless of what type of reaction might be noted. Do not attempt to distinguish between true allergies/sensitivities and intolerances, side effects, etc. (e.g., “Allergies: ACEIs – Cough” – consider as ACEI allergy).
  • Documentation of an allergy/sensitivity to one particular ACEI or one particular ARB is acceptable to take as an allergy to the entire class (e.g., “Allergic to Valsartan”- consider as ARB allergy).
  • The abstractor should search every suggested data source listed for the collection of information. When conflicting information is documented in a medical record, a positive finding should take precedence over a negative finding (e.g., answer “Yes”), unless otherwise specified.
  • In the absence of explicit documentation that the patient has moderate/severe aortic stenosis, this should be inferred when there is documentation of a history of moderate/severe aortic stenosis without mention of repair or replacement, valvuloplasty, or commissurotomy.
  • When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing an ACEI or an ARB at discharge:
    • Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions ONLY:
      -Angioedema
      -Hyperkalemia
      -Hypotension
      -Renal artery stenosis
      -Worsening renal function/renal disease/dysfunction
      Examples of statements that automatically count as contraindications to both ACEI and ARB:
      -“Creatinine high. Hold losartan.”
      -“Hx angioedema with ACEIs.”
      -“No ACEI. Bilateral renal artery stenosis.”
      -“BPs running low. Discontinue losartan.”
      -“K+5.5 – No ACEI.”
      -“Severe hypotension with ACEIs in past.”
      -“Add ARB if hyperkalemia resolves.”
    • Reasons for no ACEIs and reasons for no ARBs must be explicitly documented (e.g., “K+5.5 – No ACEI”) or clearly implied (e.g., “Severe hypotension with ACEIs in past,” “Hx ACEI-induced cough,” “ARBs contraindicated,” “Intolerant of ACE inhibitors,” “Problems with ARBs in past,” “c/o severe cough, will DC Vasotec,” “Pt. refusing all medications,” “Limited life expectancy, no further treatment,” “Supportive care only – no medications,” “ACEI therapy not indicated,” ACEI on pre-printed order form is crossed out, mid-stay order to “Hold lisinopril,” “DC valsartan” or “No ACEI/ARB” [reason not given]). If reasons are not mentioned in the context of ACEIs/ARBs, do not make inferences (e.g., Do not assume that an ACEI/ARB is not prescribed because of the patient's chronic renal disease alone).
    • Physician/APN/PA or pharmacist documentation of a hold of an ACEI or ARB or discontinuation of an ACEI or ARB that occurs during the hospitalization constitutes a “clearly implied” reason for not prescribing an ACEI or ARB at discharge. EXCEPTIONS:
      -Discontinuation of a particular ACEI or ARB in combination with documentation to start a different ACEI or ARB (switch in type of ACEI or switch in type of ARB - e.g., “DC accupril” followed by “Start Lotensin” in physician orders).
      -ACEI or ARB holds/discontinuations which are clearly labeled or identified as preop/pre-procedure.
      -Documentation of hold/discontinuation of IV ACEI.
      -Discontinuation of an ACEI or ARB at a particular dosage in combination with documentation to start a different dosage of that ACEI or ARB (increase/decrease in dosage - e.g., “DC ramipril 10 mgs. po q a.m.” followed by “Start ramipril 5 mgs. po q a.m.” in physician orders ).
      - Order for a one-time hold. One-time holds include the holding of just one dose of a medication or holding of a medication for a defined time period. The order of the one-time hold needs to be explicit and able to stand on its own (Do not cross-reference with other medical record documentation to determine one-time holds).
      Examples:
      ►“Hold captopril in a.m."
      ►"Hold Teczem x 24-48 hours"
      ►"Hold monopril this evening. Resume dose in a.m."
      ►"Hold enalapril until a.m."
      ►"Hold Capoten today”
      ►“No Hyzaar today”
      -Documentation of a conditional hold or discontinuation of an ACEI or ARB (e.g., “Hold Captopril if cough persists,” “Stop Cozaar if BP < 90 systolic”).
      -Hold/discontinuation documentation, which refers to a more general medication class (e.g., “Hold all BP meds,” “DC nephrotoxic drugs”).
    • If there is documentation of a plan to initiate/restart an ACEI or ARB, and the reason/problem underlying the delay in starting/restarting the ACEI or ARB is also noted, this constitutes a “clearly implied” reason for not prescribing ACEI or ARB at discharge.
      Examples:
      -"Pt. hemodynamically unstable. May start ACEI/ARB as outpatient.” per discharge summary – Consider as reason for not prescribing ACEI at discharge and reason for not prescribing ARB at discharge.
      -"Severe hypotension. Evaluate pt. in office for ACEI therapy” per discharge summary – Consider as reason for not prescribing ACEI at discharge and reason for not prescribing ARB at discharge.
      -“May add accupril when pt. can tolerate” per consultation note – Consider as reason for not prescribing ACEI at discharge.
      -"Begin ACEI/ARB therapy at first clinic visit" per discharge progress note – Do NOT consider as reason for not prescribing ACEI or ARB at discharge.
      -“Consider starting Cozaar in a.m.” per mid-stay progress note – Do NOT consider as reason for not prescribing ARB at discharge.
      -“Consulting cardiologist to evaluate pt. for ACEI therapy” per H&P – Do NOT consider as reason for not prescribing ACEI at discharge.
      -“Add - ARB if hyperkalemia resolves” per admitting progress note – Consider as reason for not prescribing ARB at discharge and reason for not prescribing ACEI at discharge.
    • Reasons do NOT need to be documented at the time of discharge or otherwise associated specifically with discharge prescription. Documentation of contraindications anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating no ACEIs “due to acute renal failure” - consider as reason for not prescribing ACEI at discharge and reason for not prescribing ARB at discharge, even if documentation indicates that the acute renal failure had resolved by the time of discharge and ACEI was restarted).
    • Crossing out of an ACEI or ARB order counts as an "other reason" for not prescribing an ACEI or ARB at discharge only if on a pre-printed order form.
  • In cases where there is a pre-arrival contraindication or physician/APN/PA or pharmacist documented reason for not prescribing an ACEI or ARB, the following guidelines apply regardless of whether this documentation is included in a transfer record or outpatient record made part of the current record during hospitalization or whether it is re-noted by hospital staff during the current hospitalization:
    • Notation of an ACEI or ARB allergy prior to arrival counts as a contraindication to ACEI or ARB at discharge.
    • Notation of moderate/severe aortic stenosis prior to arrival counts as a contraindication to both ACEI and ARB at discharge.
    • Pre-arrival hold or discontinuation of an ACEI or ARB or notation such as "No ACEIs" or "No ARBs" counts as a reason for not prescribing an ACEI or ARB at discharge ONLY if the underlying reason/problem is also noted (e.g., “Candesartan held in transferring hospital due to hypotension”).
    • Pre-arrival "other reason" (other than an ACEI or ARB hold/discontinuation or notation of "No ACEIs or "No ARBs") counts as reason for not prescribing an ACEI or ARB at discharge (e.g., "Intolerance to ARBs" "Hx severe hypotension with Hyzaar").

Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing notes
  • Progress notes
  • Physician orders
  • Discharge summary
  • Diagnostic test reports
  • Medication administration record (MAR)
  • Discharge instruction sheet
Excluded Data Sources:
Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay)
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Angioedema
  • Angioneurotic edema
  • Edema of the eyelid
  • Edema of the glottis
  • Edema of the larynx
  • Edema of the nasopharynx
  • Edema of the pharynx
  • Periorbital edema, described as acute

Hyperkalemia

  • Patient's potassium (K+) level noted (e.g., "Last K+ 6.5. Will hold off on ACEI therapy”)
  • Potassium (K+) level described as elevated

Hypotension

  • Blood pressure (BP) described as low
  • Patient's blood pressure (BP) measurement noted (e.g., "BP systolic running in 80s. Will not prescribe ARBs at this time”)
  • Shock
Moderate/severe aortic stenosis (AS)
  • Aortic stenosis described as 3+, 4+, critical, or significant
  • Aortic stenosis, degree of severity not specified
  • Aortic valve area of < 1.0 square cms
  • Subaortic stenosis, moderate/severe or degree of severity not specified
Worsening renal function/renal disease/dysfunction
  • Arterionephrosclerosis
  • Azotemia
  • Blood urea nitrogen (BUN) level described as abnormal or elevated
  • Blood urea nitrogen (BUN) noted (e.g., “No ARBs. BUN 21”)
  • Dialysis
  • End stage renal disease (ESRD)
  • End stage renal failure (ESRF)
  • Glomerulonephritis
  • Glomerulopathy
  • Glomerulosclerosis
  • Hemodialysis (HD)
  • Kidney disease
  • Kidney transplant (KT, s/p kidney transplant)
  • Nephritis
  • Nephropathy
  • Nephrosclerosis
  • Nephrosis
  • Nephrotic syndrome (NS)
  • Papillary necrosis
  • Peritoneal dialysis (CAPD)
  • Polycystic kidney disease
  • Renal disease
  • Renal disorder
  • Renal dysfunction
  • Renal failure, acute or chronic (ARF, RF, CRF)
  • Renal function described as abnormal, compromised, decreased, depressed, impaired, low, poor, or reduced
  • Renal insufficiency (RI, CRI)
  • Renal transplant (RT, RTx, s/p renal
transplant)
  • Serum creatinine (Cr, Cre) level described as abnormal or elevated
  • Serum creatinine (Cr, Cre) noted (e.g., “No ACEIs. Creatinine 2.0”)
  • Tubular necrosis
  • Uremia

Refer to Appendix C, Table 1.2 for a comprehensive list of ACEIs and Table 1.7 for a comprehensive list of ARBs.

ACEI allergy
ACEI allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

ARB allergy
ARB allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Moderate/severe aortic stenosis (AS)

  • Aortic insufficiency only
  • Aortic regurgitation only
  • Aortic stenosis described as 1+ or 2+
  • Moderate/severe aortic stenosis, or any of the other moderate/severe aortic stenosis inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Contraindication to Both ACEI and ARB at Discharge
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)