Spironolactone and eplerenone are mineralocorticoid receptors antagonists (MRAs) licensed for treatment of people with HFREF. New studies have investigated the role of MRAs in patients with HFpEF. The aim of this review was to examine the clinical and cost-effectiveness of MRAs in people with HFpEF. 6.2.3.2 Review question: What is the clinical and cost effectiveness of mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction? For full details see review protocol in Appendix A. Table 40: PICO characteristics of review question Population People diagnosed with heart failure with preserved ejection fraction (HFPEF). Interventions Mineralocorticoid receptor antagonist: Spironolactone (up to 50mg/day) Eplerenone (up to 50mg/day) Comparison Placebo Outcomes CRITICAL All-cause mortality Quality of life Unplanned hospitalisation IMPORTANT Improvement of NYHA class Adverse events - Renal function Adverse events Gynaecomastia Adverse events Hypotension Adverse events - Hyperkalaemia Study design Systematic Review RCT 6.2.3.3 Clinical evidence A search was conducted for randomised controlled trials comparing the effectiveness of mineralocorticoid receptor antagonists with placebo in people with heart failure with preserved ejection fraction (HFPEF) on current standard first line treatment. Two studies (reported in 11 publications) were included in the review: Treatment Of Preserved Cardiac function heart failure with Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 and Aldosterone Receptor Blockade in Diastolic Heart Failure (Aldo-DHF).108, 109 . These are summarised in Table 41 below. See also the study selection flow chart in Appendix C, forest plots in Appendix E, study evidence tables in Appendix F, GRADE tables in Appendix H and excluded studies list in Appendix I. These studies have all been excluded within this review, because they no longer meet the review protocol. 