This patient should be discharged home, with a follow-up appointment scheduled within 7 days. She has had one heart failure hospitalization in the past 3 years and her nonadherence with her diuretic medication was the most likely cause of the admission. With any heart failure hospitalization, it is important to reassess several factors before discharge. First, patients must be adequately diuresed prior to discharge. It is important to know that measuring a serum B-type natriuretic peptide level will not help with that assessment. Patients should be examined for flat neck veins, resolution of peripheral or abdominal edema (if possible), and resolution of the signs and symptoms of acute heart failure (S₃, exertional dyspnea and fatigue, orthopnea, paroxysmal nocturnal dyspnea). Second, patients should be on appropriate medical therapy for their stage of heart failure. For this patient, appropriate medications include an ACE inhibitor or angiotensin receptor blocker, β-blocker, aldosterone antagonist, and an adequate dosage of diuretic to prevent readmission. Third, it has been demonstrated that a patient being seen within 1 week after discharge is associated with a reduction of future heart failure hospitalizations. This patient is adequately diuresed and is on appropriate medications. Reducing her risk of readmission requires a follow-up visit within 7 days of discharge and appropriate patient education.

An echocardiogram performed 1 month ago demonstrated that the patient's left ventricular function is stable. There is no suggestion of ischemia or change in valvular function as a precipitant of this hospitalization. If this patient had not had an echocardiogram in at least 6 months, it would be reasonable to repeat the echocardiogram during the hospitalization; otherwise unless there is a suspicion of a change, there is no reason to do so.

Patients are candidates for a biventricular pacemaker if they have all of the following indications: on guideline-directed medical therapy, a reduced ejection fraction (≤35%), a wide QRS interval (≥150 ms) or a left bundle branch block, and New York Heart Association functional class III or IV symptoms. This patient has a narrow QRS interval and therefore would not be a candidate for upgrading to a biventricular implantable cardioverter-defibrillator.