One UK economic evaluation assessed the addition of eplerenone to optimal medical management based on the EMPHASIS-HF trial included in the clinical review. This analysis found that the addition of eplerenone to optimal medical management was more effective and more costly than optimal medical management alone, with an ICER of 3,520 per QALY gained and was therefore considered to be cost effective. The committee noted that at the time of this analysis the cost of eplerenone was around 42, however, as this drug has recently come off patent its price has significantly decreased. Therefore, the ICER will now be much lower. One Irish economic evaluation assessed the addition of spironolactone to optimal medical management based on the RALES RCT included in the clinical review. This analysis was reviewed in the previous 2010 guideline update. This analysis found that the addition of spironolactone to optimal medical management was more effective and more costly than optimal medical management alone, with an additional cost of 291 per life year gained. The main limitation of this analysis is that it does not incorporate quality of life and could therefore not be assessed using the NICE cost per QALY threshold. However, in the 2010 guideline an equivalent threshold of 13,000 per life year gained was calculated based on a utility value of 0.65, as reported in a health technology assessment by Mant et al. 2009. The committee agreed to also adopt this threshold, and the addition of MRAs to optimal medical management was considered to be cost effective. The committee noted that costs are likely to have risen since this was last reported in the previous guideline, but agreed that this would not change the overall conclusion of the result. The committee noted the higher risk of renal dysfunction for people taking MRAs. 