Once the target or maximum tolerated dose of an ARB is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell. [2010 amended 2018] 46. If neither ACE inhibitors nor ARBs are tolerated, seek specialist advice and consider hydralazine in combination with nitrate for people who have heart failure with reduced ejection fraction. [2010] 47. Offer a mineralcorticoid receptor antagonist (MRA) in addition to an angiotensin-converting enzyme inhibitor (ACE) or ARB and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure. [2018] 48. Measure serum sodium and potassium and assess renal function before and after starting an MRA and after each dose increment. [2018] 49. Measure blood pressure before and after each dose increment of MRA. Follow the recommendations on measuring blood pressure, including measurement in people with symptoms of postural hypotension, in the NICE guideline on hypertension in adults. [2018] Chronic Heart Failure Guideline summary NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 50. Once the target, or maximum tolerated, dose of an MRA is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell. [2018] 51. Ivabradine is recommended as an option for treating chronic heart failure for people: with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitor and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated and 52. 