We recommend an MRA such as eplerenone be considered for patients >55 years with mild to moderate HF on standard HF treatments with EF ≤30% (or ≤35% if QRS duration >130 ms) and recent (6 months) hospitalization for CV disease or with elevated BNP or NT-proBNP levels. (Recommendation Strong, Quality High).

We recommend an MRA such as eplerenone be considered in patients following an MI with EF ≤30% and HF or EF ≤30% alone in the presence of diabetes. (Recommendation Strong, Quality High).

We recommend an MRA such as spironolactone be considered for patients with an EF ≤30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments. (Recommendation Strong, Quality High).

Values and Preferences The above recommendations place a high value on an understanding that among a given drug class, only drugs proven to be beneficial in large trials can be used because their effective target doses capable of modifying clinical outcome are known, and less value on individual response. If a drug with proven mortality or morbidity benefits is not tolerated by the patient, other concomitant drugs with less proven benefit can be carefully reevaluated to determine whether their dose can be reduced or the drug discontinued to allow for better tolerance of the drug with proven benefit. These values and preferences also apply to the recommendations of other classes of drugs discussed below. Furthermore, as there are still no data on outcome-modifying pharmacologic treatment in HF-PEF, the above recommendations apply predominantly to patients with HF-REF.