This patient with a recent diagnosis of heart failure with reduced ejection fraction (HFrEF) should be started on a β-blocker, such as carvedilol. Standard therapy for patients with HFrEF includes an ACE inhibitor and a β-blocker. This patient is already on an ACE inhibitor for treatment of his blood pressure and for afterload reduction for his heart failure. ACE inhibitors are typically started first in patients with heart failure because of their positive hemodynamic effects. An angiotensin receptor blocker (ARB) would be another treatment option, particularly if an ACE inhibitor were not tolerated. A β-blocker should then be started in stable, euvolemic patients with heart failure, either at the time of diagnosis or after acute decompensation is treated. β-Blockers have several beneficial effects and have been shown to prolong overall and event-free survival.

The β-blockers that have been shown to provide benefit in patients with HFrEF are metoprolol succinate, carvedilol, and bisoprolol. The β-blocker dosage should be increased slowly—at 1- to 2-week intervals—to the maximal dose. Like ACE inhibitors, there are data that suggest improved outcomes on higher doses of β-blockers (increased ejection fraction, reduced symptoms, lower mortality rates); therefore, attempting to up-titrate to maximally tolerated doses is important.

Although dihydropyridine calcium channel blockers, such as amlodipine, are effective antihypertensive and antianginal medications, they do not provide the same benefits as ACE inhibitors, ARBs, or β-blockers, and would not be appropriate add-on therapy in this patient who is not currently on a β-blocker and has controlled blood pressure without angina.

This patient has clear lungs, no significant jugular venous distention, and no peripheral edema. He has no evidence of volume overload and therefore does not need a diuretic, such as furosemide. Diuretics have no mortality benefit and are only used for symptom relief in the setting of volume overload.

Spironolactone has been demonstrated to decrease mortality rates in patients with New York Heart Association (NYHA) functional class II to IV heart failure (dyspnea with activities of daily living). This patient has good exercise capacity and has NYHA class II heart failure. However, candidates for spironolactone therapy should already be on standard medical therapy, including an ACE inhibitor and a β-blocker.

Making no changes in this patient's treatment regimen would not be appropriate because he is not being treated with medications associated with improved outcomes in patients with systolic heart failure.