A 77-Year-Old Man with a Long-Standing History of Hypertension Comes

A 77-year-old man with a long-standing history of hypertension comes to the office due to exertional shortness of breath and fatigue.  He went to the emergency department 4 weeks ago for shortness of breath and was treated with intravenous diuretics.  Echocardiogram at that time showed left atrial enlargement, left ventricular hypertrophy, and a left ventricular ejection fraction of 65%.  Medications include daily furosemide 40 mg, amlodipine 10 mg, spironolactone 12.5 mg, and low-dose aspirin.
Blood pressure is 128/76 mm Hg and pulse is 74/min.  Jugular venous pressure is estimated at 9 cm H₂O.  Cardiac examination is notable for an S4 gallop and nondisplaced apical impulse.  Lung auscultation reveals bibasilar crackles.  The abdomen is nondistended and nontender to palpation.  There is bilateral pitting ankle edema.
ECG shows normal sinus rhythm and voltage criteria for left ventricular hypertrophy.  Serum potassium is 4.1 mEq/L and serum creatinine is 0.9 mg/dL.
Which of the following is the best treatment option for this patient?

A) Add hydralazine and isosorbide dinitrate
B) Add losartan
C) Add metolazone
D) Add metoprolol
E) Increase furosemide dosage

Correct Answer:

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