Further medication options after seeking specialist advice, might be sacubitril valsartan (in place of ACEi [or ARB]), digoxin, or ivabradine. For people with CKD stage III and HFREF, the evidence suggested that ACE-I are efficacious and do not result in excess renal complications (such as hyperkalaemia). The committee agreed that ACE-I should be used as part of first-line treatment, as in the general HFREF population. This approach accords with the current practice of regularly prescribing ACE-I in CKD to prevent adverse cardiovascular outcomes. However, people with both CKD and HFREF appear not to get the same increased benefit of a high dose ACEI-I seen in the general HFREF population, perhaps because of additional renal adverse effects related to the drug. The committee agreed that prescribers may wish to carefully consider the utility of titrating to the highest doses in this population, as a lower dose may be just as effective overall, when the potential harms are weighed against the benefits. The high absolute risk of hyperkalaemia was not felt to be a reason to withhold these effective drugs, but should lead to increased attention in monitoring. The evidence also suggested an overall benefit of beta-blockers as first-line treatment alongside ACE-I. This is aligned with practice, with beta-blockers being routinely prescribed in patients with HFREF and established kidney disease. The committee agreed that the evidence on MRA in the CKD/HFREF population also supported the adoption of the general recommendation that it should be prescribed if patients are still symptomatic on beta-blocker plus ACE-I. Just as for the general HFREF population, any further medication (beyond beta-blockers, ACE-I and MRA) for heart failure in people with CKD should be prescribed by, or in liaison with, a heart failure specialist. 