In this patient with recently diagnosed heart failure, the dosage of furosemide should be increased. She has signs of volume overload (elevated central venous pressure, an S3, peripheral edema, weight gain).
Given the patient's relative hypotension and volume overload, increasing her diuretic dose would be more appropriate than increasing the dose of her ACE inhibitor, which might lead to low blood pressure and would not improve her volume overload.
Although there is a mortality benefit to the use of β-blockers in patients with systolic heart failure, these agents have negative inotropic activity, and initiation of β-blocker therapy is relatively contraindicated in patients with evidence of decompensated heart failure. Once the patient has been appropriately diuresed, a β-blocker can be added. Even patients with a low systolic blood pressure, once euvolemic, can often tolerate low doses of a β-blocker.
Spironolactone is an appropriate agent to add for treatment of stable patients with New York Heart Association (NYHA) functional class II to IV heart failure. This patient, however, has acute volume overload, which should be treated before initiation of this therapy. Although spironolactone has some diuretic activity, at the usual doses prescribed for patients with heart failure (12.5-25 mg/d), it would not have sufficient diuretic effect in this patient.
This patient's presentation demonstrates the importance of an early (within 7 days) post-hospital clinic visit for patients after a hospitalization for heart failure. Recognizing volume overload at a point when it can be treated on an outpatient basis is an example of the benefit of this visit. If the patient were euvolemic, adding additional therapy, such as a β-blocker or spironolactone, would be appropriate. This visit also allows the internist to reemphasize to the patient the importance of medication adherence and fluid restriction.