The study also reports that even if 4 additional outpatient visits were assumed that spironolactone is still highly cost-effective. Taking this into consideration the committee agreed that MRAs would still remain highly cost-effective and therefore should be offered to chronic heart failure patients with reduced ejection who remain symptomatic on current first line therapy. Other considerations The committee considered that the introduction and continuation of MRAs, as with all pharmaceuticals in heart failure, should be part of shared decision making, and noted that this was already reflected in recommendation [85] in the communication section of the chronic heart failure guidance. A lay committee member raised the issue of polypharmacy and whether, if a person s heart function improves significantly, one or more of medications could be discontinued. The clinical committee members acknowledged the understandable desire of patients to not take more medications than required and the burden of polypharmacy. There are no large-scale trials addressing this question so evidence in this regard is lacking. Healthcare professionals should ensure that patients are on appropriate polypharmacy while taking into account that the reduction or removal of particular medications, even in controlled heart failure, has empirically been noted to lead to deterioration of heart function and risk of arrhythmia. The decision to discontinue therapies should therefore be made on an individual patient basis, as part of shared decision with the patient as part of the wider multi- disciplinary team, with full discussion of potential risks and benefits and taking into account patient side-effects and symptoms. The committee discussed current practice regarding the prescribing of MRAs, and the potential impact of their recommendation. In the 2010 guideline, MRAs can be considered as one of several second line treatment options, after specialist advice. 