A 55-year-old man presents with gradually increasing shortness of breath and leg swelling over the past month. He has also noticed orthopnea and paroxysmal nocturnal dyspnea. He takes simvastatin for hypercholesterolemia and hydrochlorothiazide for hypertension. Blood pressure is 140/90 mm Hg; there is mild jugular venous distension, soft bibasilar crackles, an S3 gallop, and minimal pedal edema. An echocardiogram shows left ventricular ejection fraction (LVEF) of 40% without segmental wall-motion abnormality. The patient desires to keep medications to a minimum What change in his management would you recommend at this time?

There is very good evidence that ACE inhibitors should be used in patients with heart failure (HF) and a depressed left ventricular ejection fraction. ACE inhibitors stabilize left, ventricular remodeling, improve symptoms, reduce hospitalization, and decrease mortality. Beta- blocker therapy represents a major advance in the treatment of patients with HF and depressed systolic function. These drugs interfere with the harmful effects of sustained activation of the adrenergic nervous system by competitively blocking beta-receptors. When given with ACE inhibitors, beta-blockers stabilize left ventricular remodeling, improve patient symptoms, reduce hospitalization, and decrease mortality. An aldosterone antagonist is recommended for patients with NYHA class III or IV symptoms who have a left ventricular ejection fraction of less than 35% and who are still symptomatic despite receiving standard therapy with diuretics, ACE inhibitors, and beta-blockers. Likewise, digoxin may improve symptoms and decrease hospitalization rates in patients with HF but has not been shown to prolong life. Neither of these drugs is indicated in this patient with mild symptoms. Furosemide is used to improve symptoms but does not prolong survival. Since this patient wants to minimize medications, an ACE inhibitor and beta-blocker are better first choices because they confer a survival advantage. An implantable defibrillator is indicated in systolic heart failure with left ventricular ejection fraction less than 35% in order to prevent sudden cardiac death but is not indicated in this patient whose ejection fraction is 40%.