MRAs: For the comparison of MRA versus placebo the evidence ranged from low to very low quality. HF hospitalisations (n=792) suggested a clinically important reduction with MRAs. This was also the case for the combined outcome of cardiovascular mortality and HF admission (n=912) (associated with wide confidence intervals around the effect estimate). For the outcome hyperkalemia the evidence suggested a clinically important increase with MRAs (n=1675). Mortality (n=792) did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality. Economic No relevant economic evaluations were identified. 6.2.6.6 Recommendations and link to evidence Recommendations For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR of 30ml/min/1.73 m2 or above: Offer the treatment outlined in section 6.2.7 and If the person s eGFR is 45ml/min/1.73 m2 or below, consider lower doses and/or slower titration of dose of ACE inhibitors or ARBs, mineralocorticoid receptor antagonists and digoxin. [2018] For people who have heart failure with reduced ejection fraction and chronic kidney disease with an eGFR below 30 ml/min/1.73 m2 , the Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 specialist heart failure MDT should consider liaising with a renal physician. Monitor the response to titration of medicines closely in people who have heart failure with reduced ejection fraction and chronic kidney disease, taking into account the increased risk of hyperkalaemia. [2018] Relative values of different outcomes The committee agreed that all-cause mortality, all-cause unplanned hospitalisation and quality of life were the most critical outcomes for determining the efficacy and potential harms of heart failure medications in people with CKD. 