[2012] Sacubitril valsartan These recommendations are from Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction (NICE technology appraisal guidance 388)a . 54.Sacubitril valsartan is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people With New York Heart Association (NYHA) class II to IV symptoms and With a left ventricular ejection fraction of 35% or less and Who are already taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor-blockers (ARBS) [2016] 55.Treatment with sacubitril valsartan should be started by a heart failure specialist with access to a multidisciplinary heart failure team. Dose titration and monitoring should be performed by the most appropriate team members as defined in NICE s guideline on chronic heart failure in adults: diagnosis and management. [2016] 56.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 fraction).[2010] 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 58.Digoxin is recommended for worsening or severe heart failure with reduced ejection fraction despite first line treatment for heart failureb . Seek specialist advice before 59.Routine monitoring of serum digoxin concentrations is not recommended. 