Treating Heart Failure Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 6.2.6.4 Economic evidence Published literature No relevant health economic studies were identified. See also the health economic study selection flow chart in Appendix D. 6.2.6.5 Evidence statements Clinical Twelve studies were identified for inclusion within the review. The majority of the evidence was from subgroup analyses of trials in the general HFREF population. The studies included comparisons of different classes of medicine including angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, digoxin, ivabradine and mineralocorticoid receptor antagonists with placebo in people with chronic kidney disease (specifically at least stage IIIa). Outcomes were analysed by disease severity, where this information was reported by the paper. Evidence was also found comparing high dose ARB with low dose ARB and high dose ACE-inhibitor with low dose ACE- inhibitor. The evidence ranged from low to very low quality with the majority being rated as very low quality. This was based on a number of contributory factors including risk of bias and imprecision due to wide confidence intervals. The studies frequently used a composite outcome of death or hospitalisation, which led to the evidence being downgraded for indirectness. No evidence was identified for the outcomes QoL, arrhythmic events or progression to stage 5 kidney disease/unplanned dialysis. In addition to this no evidence was identified for the interventions of loop diuretics; sacubitril-valsartan; or hydralazine-nitrate versus placebo. Furthermore, no inter or intra class comparisons were identified. 