Furthermore, taking the technology appraisals into consideration, sacubitril valsartan and ivabradine recommendations were added as possible specialist treatments. The committee recognised that the strengthening of the recommendation to offer MRAs for this population could have a significant resource impact for the NHS due to increased prescribing volume. However, there was good economic evidence suggesting that the addition of MRAs for patients with heart failure with reduced ejection fraction in the community is cost- effective. Although spironolactone is currently cheaper than eplerenone the committee decided not to specify which drug should be prescribed and agreed that this should be the decision of the prescribing clinician while taking into account the pharmacological differences of the 2 medicines, as there has been no head to head comparison trial of the 2 drugs. The previous guideline for chronic heart failure (CG108) included 8 studies which are referenced in the clinical review. Seven of these studies have been excluded within the current review as they no longer meet the review protocol. The committee discussed the protocol for this review question and agreed that the previously included studies which had a population of people with heart failure post myocardial infarction were not appropriate for consideration within the review as these people represented a significantly different population. In addition to this the committee agreed that the minimum duration of follow-up for included studies should be 6 months and have a minimum sample size of 100 to ensure an accurate clinical effect can be established. In addition to this, the committee agreed that cross-over studies should be excluded to ensure that potential carryover effects are not confounding the outcome. Chronic Heart Failure Treating Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. 