Evidence quality was very low for improvement in NYHA class (due to risk of bias, indirectness and imprecision), meaning that the committee placed little weight on this outcome in their decision making. Trade-off between clinical benefits and harms There was moderate quality evidence estimating 13 fewer deaths per 1000 patients and high quality evidence estimating12 fewer hospitalisations per 1000 patients per year in people taking mineralocorticoid receptor antagonists (MRAs). The committee noted that although the confidence intervals were mostly indicating beneft there was also indication of increased mortality and hospitalisation There was also moderate quality evidence (from a smaller study that did not report number of events) that suggested an increase in the number of patients hospitalised for any cause in the intervention group compared to the placebo group, though this evidence was imprecise. Based on the body of evidence, the committee concluded that it was unclear whether MRAs have a clinical benefit, a clinical harm, or no effect on mortality and hospitalisation in this population. The committee discussed the clinically important harm of MRAs on renal function (estimate of 77 more patients experiencing worsening renal function per 1000 in the intervention group) and hyperkalaemia (estimate of 87 more per 1000). They also noted the increased risk of gynaecomastia in patients taking spironolactone (estimate of 17 more per 1000), and that all of these effect estimates were subject to a high risk of bias likely to underestimate the effect. The committee also acknowledged that the use of MRAs had no clinically important impact on quality of life or NYHA class. The committee was aware that post hoc analyses of the principle trial (TOPCAT) suggested a considerable degree of heterogeneity within the population recruited and that MRAs might habe differential effcts in the different groups. 