The African- American Heart Failure Trial (A-heFT)270 showed that a com- bination of a fixed dose of isosorbide dinitrate and hydralazine provides additional benefit in African American patients with advanced HF. The trial was stopped early because of a signifi- cantly higher mortality rate in the placebo group than in the group receiving isosorbide dinitrate plus hydralazine (10.2% Therefore, for African Americans who require further BP control and relief of symptoms of HF (NYHA class III or IV), the combination of hydralazine and isosorbide is recommended together with ACE inhibitors, -blockers, and aldosterone antagonists.271 Given the lack of randomized trial evidence to support the prevention of car- diovascular events by the use of hydralazine in the treatment of primary hypertension272 and concerns that hydralazine may provoke angina, monotherapy with hydralazine in IHD is not recommended. 6.7.6. Aldosterone Receptor Antagonists Aldosterone has been shown to promote myocardial fibrosis. RALES reported the effect of adding the competitive aldoste- rone antagonist spironolactone versus placebo to standard HF therapy in patients with stage 3 (NYHA class III or IV) HF.There was a 30% reduction in total mortality with spironolactone.111 Eplerenone, a selective aldosterone inhibitor, showed similar survival benefit in the EPHESUS trial. Patients with an LV ejec- tion fraction of <40% were randomly assigned at 3 to 14 days after MI to therapy with eplerenone or placebo. 