Recommendation 43: We recommend against the use of both non-steroidal anti-inflammatories and cyclooxygenase-2 (COX-2) inhibitors in patients with HFrEF (Strong Recommendation, High Quality Evidence).

Values and preferences: These agents may cause sodium and water retention, worsen renal function, interact with HF medications (ACEi/ARB), increase cardiovascular events and worsen HF. Preference is given to reducing drug-related adverse outcomes and should take into account patient preference for pain control and quality of life.

• High doses of ASA may share the same risks as nonsteroidal anti-inflammatory drugs (NSAIDs) and may aggravate HF, especially in unstable patients.