Because of their negative inotropic properties and the increased likelihood of worsening HF symptoms, nondihydropyridine CCBs such as diltiazem and verapamil should be avoided.278 The dihydropyridine CCB amlo- dipine appeared to be safe in patients with severe systolic HF in the Prospective Randomized Amlodipine Survival Evaluation as was felodipine as supplementary vasodila- tor therapy in the Vasodilator-Heart Failure Trial (V-HeFT) III.280 Although clonidine is an effective antihypertensive agent, another druginthesameclass,moxonidine,wasassociatedwithincreased mortality in patients with HF281 ; therefore, clonidine also should probably be avoided. In the ALLHAT trial, the doxazosin arm of the trial was discontinued because of a 2.04-fold increase in rela- tive risk of developing HF compared with chlorthalidone treat- Although there are several caveats about extrapolating these data to the management of hypertension in patients with HF, -blockers should be used only if other agents used for the management of hypertension and HF are inadequate to achieve good BP control, and even then, they should be used with cau- tion. Nonsteroidal anti-inflammatory drugs have been associated with increased BP accompanied by peripheral edema, weight gain, and worsening renal function, so they should be used with caution in HF patients.283,284 Studies of the direct renin inhibitor aliskiren added to ACE inhibitors or ARBs were stopped early because of concerns about increased adverse events, particularly in the setting of renal insufficiency or diabetes mellitus. Ongoing trials of aliskiren in HF with heightened safety monitoring should help define the role, if any, for this agent. Given the lack of ran- domized trial evidence to support the use of hydralazine without a nitrate in the treatment of primary hypertension and concerns that hydralazine may provoke angina, monotherapy with hydrala- zine in IHD is not recommended. 1. 