This patient should have hydralazine and isosorbide dinitrate added to her medication regimen for the treatment of her heart failure. She has New York Heart Association (NYHA) functional class III heart failure and is black. Hydralazine and isosorbide dinitrate have been demonstrated to improve symptoms and reduce mortality in patients who are black and who are already on maximal therapy with NYHA class III or IV heart failure symptoms. Adverse effects of this therapy include peripheral edema and headaches, but this regimen should be attempted in these patients.

Optimal therapy for patients with heart failure includes treatment with an ACE inhibitor, β-blocker, and an aldosterone antagonist. The addition of an angiotensin receptor blocker, such as losartan, to this combination is generally not recommended, primarily because of concern for hyperkalemia. Additionally, no benefit to this treatment regimen has been documented. It would therefore not be appropriate in this patient.

In patients with heart failure, warfarin treatment is appropriate only in those with another indication, such as atrial fibrillation meeting CHA₂DS₂-VASc criteria, but not with heart failure alone. The routine treatment of patients with heart failure with warfarin is not indicated.

Cardiac resynchronization therapy (CRT) may be an effective therapy in patients with heart failure and a prolonged QRS duration indicating dyssynchrony. Indications include a left ventricular ejection fraction of 35% or less in patients in sinus rhythm, with a left bundle branch block, and with a QRS duration of 150 ms or greater in whom moderate to severe symptoms (NYHA class III or IV) are present despite optimal medical therapy. Because this patient does not have evidence of dyssynchrony or an ejection fraction of 35% or less, she is not a candidate for treatment.