Thus, CCBs are alternatives to -blockers in the treatment of angina pectoris but are not recommended for secondary cardiac pro- tection because of the relative lack of benefit of this class in particularly compared with ACE inhibitors96 2.1.7. Direct Renin Inhibitors The direct renin inhibitor aliskiren lowers BP alone or when added to other antihypertensive agents but has not been shown to have protective effects in patients with CVD, including In 2011, the Aliskiren Trial In Type 2 Diabetes Using Cardio-Renal Disease Endpoints (ALTITUDE) was stopped on the recommendation of its Data Monitoring Committee.119 ALTITUDE was comparing placebo with aliskiren 300 mg once daily added to background ACE inhibitor or ARB ther- apy in patients with diabetes mellitus and either increased urinary albumin excretion or both a reduced estimated glo- merular filtration rate and established CVD. The primary out- come in ALTITUDE was a composite of cardiovascular death, resuscitated sudden death, nonfatal MI, nonfatal stroke, hospi- talization for HF, end-stage renal disease, renal death, or dou- bling of baseline serum creatinine concentration, sustained for at least a month. The basis for stopping the trial was futility for success and safety concerns, including renal dysfunction, hyperka- lemia, hypotension, and an excess of strokes. The number of patients experiencing a nonfatal stroke in the placebo group was 85 (2.0%) and in the aliskiren group was 112 (2.6%; unadjusted P=0.04). Given prior data relating the use of antihypertensive therapy to a reduced incidence of stroke in patients with diabetes mellitus, it is possible that the imbal- ance in strokes represents a chance finding. Nevertheless, the general recommendation at present is to avoid the use of aliskiren in combination with another renin-angiotensin blocking agents in patients with hypertension for the pri- mary prevention of CVD. 3. BP Goals 3.1. 