In the 2010 guideline, MRAs can be considered as one of several second line treatment options, after specialist advice. The new recommendation is stronger than the previous recommendation on the use of MRAs ( offer rather than consider ) and the suggestion to seek specialist advice prior to introduction has been removed. This is due to the strengthening of the evidence base and the recognition of local variation in heart failure multidisciplinary teams. Further, it is in line with the recommendations in the Acute Heart Failure guideline (CG187), from which many patients are likely to transition to chronic management. In formulating the new recommendation, the committee discussed the patient population to whom the recommendation should apply. RALES required an entry ejection fraction (EF) of 35%, and EMPHASIS 30%. The committee agreed that this was critical to the studies designs to ensure that the correct population was being studied, but that there is some variation about the measurement of ejection fraction. Accordingly MRAs should be offered to all people with HFREF, as the evidence indicated a beneficial effect across the disease severity spectrum and is likely to remain cost effective. The committee considered whether MRAs should be offered to all people Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 with HFREF who remain symptomatic on after the optimisation of beta- blocker and ACEi dose titration. The committee did not consider that the evidence supported the initiation of triple therapy immediately following diagnosis of HFREF, as the patient populations included in the review were all symptomatic on existing first line treatment. Furthermore, taking the technology appraisals into consideration, sacubitril valsartan and ivabradine recommendations were added as possible specialist treatments. 