This guidance is not intended to affect the position of patients whose treatment with sacubitril valsartan was started within the NHS before this guidance was published. Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop. [2016] Hydralazine in combination with nitrate 57. Seek specialist advice and consider offering hydralazine in combination with nitrate (especially if the person is of African or Caribbean family origin and has moderate to severe heart failure [NYHA class III/IV] with reduced ejection Digoxin For recommendations on digoxin for people with atrial fibrillation see the section on rate and rhythm control in the NICE guideline on atrial fibrillation Chronic Heart Failure Guideline summary NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 58. Digoxin is recommended for worsening or severe heart failure with reduced ejection fraction despite first line treatment for heart failure. Seek specialist advice before initiating.[2010, amended 2018] 59. Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8 12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence[2003] 60. the serum digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within the therapeutic 61. For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR of 30 ml/min/1,73 m2 or above: (estimated glomerular filtration rate) as follows. Offer the treatment outlined in section 6.2.7 and If the person s eGFR is 45 ml/min/1.73 m2 or below, consider lower doses and/or slower titration of dose of ACE inhibitors or ARBs, mineralcorticoid receptor antagonists and digoxin. [2018] 62. 