Cardiovascular Diseases Questions

A 58-year-old man presents to the emergency department with retrosternal chest pain. He has 20-pack-year smoking history. An ECG reveals T-wave inversion in leads V2–V5. Initial lab testing shows elevated troponin level. The patient is started on aspirin, enoxaparin, nitroglycerin, and atorvastatin.
Which additional medication is most appropriate to add at this time?

A previously healthy 46-year-old woman presents to the clinic with several-month history of progressive shortness of breath. Vital signs are within normal limits. Physical examination reveals jugular venous distension, abdominal distension, and bilateral 2+ pitting edema. Cardiac auscultation demonstrates muffled heart sounds.
Which one of the following is the most likely diagnosis?

A 67-year-old man with hypertension, diabetes, and previous transient ischemic attack presents to the emergency department with palpitation lasting several hours. Vital signs show blood pressure of 120/80 mm Hg, heart rate of 70 bpm, respiratory rate of 16 bpm, and oxygen saturation is 99% on room air. An ECG reveals irregularly irregular rhythm at 75 bpm.
Which one of the following is the most appropriate next step in management?

A 46-year-old man with no past medical history presents for routine health assessment. Office blood pressure measured is 148/92 mm Hg. He provides log of home BP readings showing average daytime of 122/78 mm Hg. Physical examination is unremarkable and recent laboratory studies are within normal limits.
What is his estimated 10-year risk for major adverse cardiovascular event?

A 59-year-old man presents to the emergency department with retrosternal chest pain. His past medical history is unremarkable except for 20-pack-year smoking history. An ECG reveals T-wave inversion in leads V2–V5. Initial lab testing shows elevated troponin level. The patient is started on aspirin, statin, and anticoagulation therapy.
Which additional medication is most appropriate to initiate at this time?

A previously healthy 64-year-old man presents to the clinic for routine checkup visit. On physical examination, high-pitched, midsystolic ejection murmur is heard best at the right upper sternal border, with radiation to the neck and carotid arteries.
Which of the following is the most likely cause of this murmur?

A 59-year-old man presents to the emergency department with substernal chest pressure that began 30 minutes ago. The pain radiates to his left shoulder and is not relieved by rest. He has 20-pack-year smoking history. A chest X ray is within normal. An ECG reveals T-wave inversion in leads V2-V5. Initial laboratory test shows elevated troponin level.
Which one of the following is the most likely diagnosis?

A 69-year-old man presents to the clinic with dry cough for several weeks. He reports no fever, night sweats, dyspnea, or weight loss. His past medical history includes hypertension, diabetes, and ischemic heart disease. His current medications include insulin, aspirin, amlodipine, lisinopril, metoprolol, and atorvastatin. Physical examination and routine laboratory results are within normal limits.
Which of the following medications is the most likely cause of his dry cough?

A 57-year-old man with smoking history and hypertension presents for evaluation of chest discomfort. He reports intermittent substernal pressure that radiates to the left shoulder over the past few months. Symptoms occur while walking, last approximately 5 minutes, and resolve with rest. An ECG is normal.
Which one of the following is the most likely diagnosis?

A 65-year-old woman is admitted with acute myocardial infarction. She undergoes successful percutaneous coronary intervention with stent placement. Two days later, she suddenly develops severe shortness of breath. On examination, her blood pressure is 90/60 mmHg, heart rate is 110 bpm, and oxygen saturation is 88% on room air. Cardiac auscultation reveals harsh holosystolic murmur best heard at the apex, radiating to the left axilla.
Which one of the following is the most likely diagnosis?

A 60-year-old man with diabetes presents to the clinic for routine annual examination. He reports progressive dyspnea when walking over the past several months. The symptom resolves with rest. He denies any substernal chest discomfort or palpitations. Vital signs are within normal limits. Physical examination is unremarkable.
Which one of the following is the most likely diagnosis?

A 58-year-old female patient with diabetes, hypertension, and hypothyroidism is being discharged after myocardial infarction treated with primary percutaneous coronary intervention. She expresses concern about her risk of recurrent cardiovascular events
Which of the following is the most appropriate strategy to reduce her risk of recurrent myocardial infarction?

A 60-year-old woman with diabetes presents to the clinic for evaluation. He reports new-onset recurrent exertional chest pain that resolves with rest. Her blood pressure is 125/72 mm Hg, heart rate is 71 bpm, and respiratory rate is 16 bpm. Physical examination is unremarkable. An electrocardiogram reveals T-wave inversions in leads V1–V3.
Which one of the following is the most appropriate next step in management?

A 64-year-old woman with diabetes, hypertension, and congestive heart failure underwent elective hysterectomy. Two days later, the nurse reported declining oxygen saturation and progressive dyspnea. Physical examination revealed bibasilar crackles and jugular venous distension.
Which one of the following is the most appropriate action to prevent this complication?

A 62-year-old man presents to the clinic with several-month history of shortness of breath. He has 35-pack-year smoking history. Vital signs are within normal limits. On exam, he has jugular venous distension, loud P2 heart sound, and 2+ bilateral pitting edema.
Which one of the following is the most likely diagnosis?

A 65-year-old man with no significant past medical history presents to the clinic with chest pain. The pain is exertion-related, typically lasts about 5 minutes, and resolves with rest. Physical examination is unremarkable. An ECG shows no abnormalities. The pretest probability for coronary artery disease is estimated at 16.9%.
Which one of the following is the most appropriate next step in management?

A 58-year-old man presents to the emergency department with retrosternal chest pain. He has 20-pack-year smoking history. An ECG reveals T-wave inversion in leads V2–V5. Initial lab testing shows elevated troponin level. The patient is started on aspirin, bisoprolol, enoxaparin, and atorvastatin.
Which one of the following is the recommended medication to add at this time?

A 58-year-old woman is discharged following myocardial infarction treated with primary percutaneous coronary intervention. His medications include aspirin, metoprolol, lisinopril, atorvastatin, and sublingual nitroglycerin as needed. Two days later, she presents to the emergency department with swelling of the tongue and face.
Which of the following medications is the most likely cause of her symptoms?

A 64-year-old man with diabetes, hypertension, and congestive heart failure presents to the clinic with left calf swelling for 3 days. His current medications include insulin, chlorthalidone, enalapril, and carvedilol. Laboratory studies reveal normal serum creatinine and elevated plasma potassium.
Which of the patient’s medications is the most likely cause of his hyperkalemia?

A 62-year-old woman with hypertension and chronic systolic heart failure is admitted for elective hysterectomy. At evening, she develops progressive dyspnea at rest. On exam, she has S3 gallop, jugular venous distension, and bibasilar crackles. An ECG shows sinus tachycardia. Chest radiograph reveals cardiomegaly with bilateral pulmonary interstitial infiltrates.
Which of the following is the most appropriate treatment at this time?

A 50-year-old woman with diabetes and osteoarthritis presents to the clinic for follow-up visit. Blood pressure measurements are elevated at 154/98 mm Hg on repeated readings. Laboratory workup, including CBC, blood chemistry profile, and TSH level, reveals potassium below the lower limit of normal.
Which one of the following is the most likely cause of her elevated blood pressure?

A 61-year-old man presents for routine health examination. He has no significant past medical history. Vital signs are normal. On cardiac auscultation, grade 3/6 midsystolic murmur is heard best at the right second intercostal space. The murmur radiates to both carotid arteries. An echocardiogram shows severe aortic leaflet calcification with restricted systolic opening, peak aortic jet velocity 4.5 m/s, and left ventricular ejection fraction 40%.
Which one of the following is the most appropriate next step in management?

A 69-year-old woman with diabetes presents to the clinic for routine follow-up. She has no symptoms. Her blood pressure is 155/92 mm Hg, heart rate is 61 bpm, and respiratory rate is 16 bpm. Physical examination is within normal limits. ECG is unremarkable.
Given her elevated blood pressure, which antihypertensive medication is the most appropriate to initiate?

A 69-year-old man with COPD, diabetes, and hypertension presents to the clinic with dyspnea on exertion over the past 2 weeks. He was hospitalized for heart failure with reduced ejection fraction 5 months ago. Vital signs show blood pressure of 152/94 mm Hg, heart rate of 88 bpm, respiratory rate of 22 bpm, and oxygen saturation of 89% on room air.
Which of the following laboratory markers would best help rule out heart failure as the cause of his dyspnea?

A 66-year-old woman presents to the emergency department with palpitations for two hours. She has history of hypertension treated with lisinopril. On examination, her vital signs show irregular pulse of 140 bpm and blood pressure of 90/60 mmHg. An ECG reveals atrial fibrillation with rapid ventricular response.
Which one of the following is the most appropriate next step in management?

A 72-year-old woman presents with progressive fatigue and mild dyspnea on exertion over the past several months. On cardiac auscultation, harsh crescendo-decrescendo systolic murmur is heard best at the left lower sternal border. The murmur increases in intensity and duration during inspiration.
Which one of the following is the most likely diagnosis?

A 54-year-old man with hypertension and diabetes presents for follow-up visit. He was recently diagnosed with heart failure with ejection fraction of 35%. He reports mild dyspnea on exertion but sleeps flat without nighttime awakening or ankle swelling.
Which of the following medication classes has been shown to reduce mortality in this patient?

A 64-year-old woman with diabetes presents to the emergency department with acute chest pain. Vital signs show blood pressure of 85/50 mmHg and heart rate of 42 bpm. Chest is clear. An ECG reveals ST-segment elevation in leads II, III, and aVF.
Which one of the following is the most appropriate initial management for bradycardia?

A 37-year-old man presents to the clinic with progressive shortness of breath over several months. His vital signs are stable. On cardiac auscultation, low-pitched, late diastolic rumble is heard best at the apex.
Which of the following is the most appropriate initial test to confirm the diagnosis?

A 68-year-old man with diabetes and osteoarthritis presents to the clinic with exertional dyspnea over the past few weeks. Physical examination reveals bibasilar crackles and jugular venous distension. An ECG shows normal sinus rhythm. Laboratory tests are within normal limits.
Which one of the following is the most appropriate next step in management?

A 35-year-old man reports progressive exertional dyspnea over the past several months. He denies chest pain, fever, or cough. Vital signs are normal. Cardiac auscultation at the apex reveals low-pitched, late diastolic murmur and high-pitched opening snap.
Which one of the following is the most likely diagnosis?

A 19-year-old man presents to the emergency department with palpitation. Vital signs show temperature of 36.5◦C, heart rate of 165 bpm, blood pressure of 150/80 mm Hg, respiratory rate 20 bpm, and oxygen saturation of 96% on room air. Physical examination is unremarkable. An ECG reveals supraventricular tachycardia.
Which one of the following is the most appropriate next step in management?

A 60-year-old man with diabetes is admitted for chest pain. Vital signs show blood pressure of 110/70 mmHg and heart rate of 76 bpm. Cardiac exam is normal except for S4 gallop. An ECG reveals ST-segment depressions in leads II, III, and aVF. Echocardiogram shows no wall motion abnormalities, normal LV function. Troponin is 0.001 pg/mL (<0.2 pg/mL, normal). The patient is started on aspirin, bisoprolol, enoxaparin, atorvastatin, and nitrates. Which one of the following is the recommended medication to add at this time?

A 27-year-old man presents to clinic for routine checkup. He is asymptomatic. Vital signs are within normal limits. Cardiac auscultation reveals diastolic murmur heard best at the left lower sternal border with the patient leaning forward at end-expiration.
Which of the following is the most likely diagnosis?

A 35-year-old man presents to the emergency department with substernal chest pain radiating to his left arm. The pain worsens when lying supine and improves when he leans forward. He reports rhinorrhea, abdominal pain, and fever before one week. Vital signs show blood pressure of 135/80 mm Hg, heart rate of 112 bpm, and respiratory rate of 20 bpm. Cardiac auscultation reveals friction rub best heard at left sternal border. An ECG reveals diffuse ST-segment elevation in all leads.
Which one of the following is the most likely diagnosis?

A 25-year-old woman presents with progressive dyspnea on exertion and cyanosis. Vital signs are normal. On exam, jugular venous pressure is elevated with prominent a-wave. A left parasternal heave is palpable. Auscultation reveals ejection systolic murmur loudest at the left upper sternal border. The murmur's intensity increases during inspiration. A high-frequency ejection click is heard following the first heart sound in the same area.
Which one of the following is the most likely diagnosis?

A 41-year-old woman presents to the emergency department with chest pain for two days. She reports that the pain worsens when she is lying supine and relieves by sitting forward. An ECG shows diffuse ST-segment elevation with PR depression.
On physical examination, which of the following findings is most likely to be present?

A 70-year-old woman with diabetes presents to the clinic for routine annual examination. She reports recurrent chest pain during physical activity relieved by sublingual nitroglycerin. The pain does not occur at rest. Physical examination is within normal limits.
Which one of the following is the most likely diagnosis?

A 52-year-old man presents with progressive shortness of breath and fatigue over the past several months. On cardiac auscultation, pansystolic murmur is heard at the apex, radiating to the axilla. An ECG shows left atrial enlargement and nonspecific ST-T changes.
Which one of the following is the most likely diagnosis?

A 45-year-old patient presents to the clinic for evaluation of cardiac murmur. On cardiac auscultation, late-peaking systolic murmur is audible at the left sternal border and apex. The murmur increases in intensity with sustained handgrip and decreases during the strain phase of the Valsalva maneuver.
Which one of the following is the most likely diagnosis?

A 69-year-old man presents to the clinic with dry cough for three weeks. He has hypertension, diabetes, and ischemic heart disease. His current medications include insulin, aspirin, amlodipine, lisinopril, metoprolol, and atorvastatin. The examination and laboratory work are all unremarkable.
Which one of the following is the most appropriate next step in management?

A 62-year-old man presents for preoperative evaluation to elective inguinal hernia repair. His medical history includes type 2 diabetes, seasonal allergies, and hypertension. He takes three antihypertensive medications, but blood pressure readings are significantly high.
Which of the following medications is most likely contributing to his poorly controlled hypertension?

A previously healthy 40-year-old man is evaluated for sudden loss of consciousness while exercising at the gym. Vital signs are within normal limits. The chest is clear. A cardiac exam reveals grade 3/6 systolic murmur, loudest at the lower left sternal border, which intensifies with standing and leaning forward with no radiation. An ECG shows nonspecific t-wave changes.
Which one of the following is the most likely diagnosis?

A 57-year-old man with hypertension presents for routine checkup. He reports no dyspnea, chest discomfort, or palpitations. Cardiovascular examination reveals harsh, late-peaking systolic murmur best heard at the right second intercostal space with radiation to the carotids. An echocardiogram demonstrates severe aortic valve calcification with restricted leaflet motion, peak aortic jet velocity 4.7 m/s, mean transvalvular gradient 42 mm Hg, and left ventricular ejection fraction 55%.
Which one of the following is the most appropriate next step in management?

A 62-year-old man with hypertension and diabetes presents to the emergency department with acute chest pain for 30 minutes. Vital signs show blood pressure of 135/80 mm Hg, heart rate of 92 bpm, and respiratory rate of 16 bpm. An ECG reveals ST-segment elevation in leads V2-V5. Initial lab testing shows elevated troponin level. The patient is transferred to the ICU because the hospital’s cardiac catheterization is unavailable.
Which of the following is the most appropriate initial medical therapy?

A 45-year-old man with hypertension presents for follow-up visit. His current blood pressure is 138/86 mm Hg. He was recently started on once-daily oral medication that selectively blocks the angiotensin receptor.
Which of the following medications was most likely prescribed?

A 64-year-old woman with diabetes presents to the emergency department with acute chest pain. Vital signs show hypotension. On exam, he has elevated jugular venous pressure and distended neck veins. Chest is clear. An ECG reveals ST-segment elevation in leads II, III, and aVF.
Which one of the following is the most appropriate initial management for cardiogenic shock in this patient?

A 57-year-old man with hypertension and smoking history reports recurrent substernal chest pressure. The pain is radiating to the left arm, precipitated by exertion and relieved by rest within 5 minutes. He states these episodes have occurred for the past year without change until 3 weeks ago, when he began to feel similar discomfort while watching television or reading. Vital signs and cardiac examination are unremarkable.
Which one of the following is the most likely diagnosis?

A 60-year-old man reports progressive dyspnea on exertion for 6 months. He has no chest pain or syncope. Blood pressure is 150/60 mm Hg. Cardiac examination reveals diastolic murmur at the left sternal border. Lung auscultation shows inspiratory crackles at both bases. An echocardiography demonstrates severe aortic regurgitation with left ventricular ejection fraction of 40%.
Which of the following is the most appropriate next step in management?

A 41-year-old man presents to the clinic for follow-up visit. He is diagnosed with hypertension and treated with two antihypertensive medications at maximum doses. His home readings average is 165/95 mm Hg. He reports episodes of headache, sweating, and dyspnea which resolve spontaneously within 15–20 minutes. Abdominal CT reveals right suprarenal mass.
Which of the following is the most appropriate added medication to control his hypertension?

A 70-year-old woman with diabetes presents to the clinic for annual check-up. She reports recurrent chest pain that occurs during walking and resolves with rest. The pain does not occur at home or during sleep. Vital signs are stable. Physical examination is unremarkable. An ECG reveals T-wave inversions in leads V2–V5.
Which one of the following is the most likely diagnosis?

A 31-year-old woman with rheumatic mitral stenosis presents for routine follow-up. She was recently diagnosed with atrial fibrillation and started on warfarin therapy. She has no history of stroke or transient ischemic attack.
What is the most appropriate target INR range for this patient?

A 62-year-old man with hypertension and diabetes presents to the emergency department with acute onset of substernal chest pressure radiating to the left arm for 30 minutes. Vital signs show blood pressure of 135/80 mm Hg, heart rate of 92 bpm, and respiratory rate of 16 bpm. An ECG reveals ST-segment elevation in leads II, III, and aVF.
Which one of the following is the most likely diagnosis?

A 78-year-old woman is evaluated for episodes of syncope that occur with physical exertion. Examination reveals delayed and slow-rising carotid pulse, and loud harsh crescendo-decrescendo murmur. The murmur is best auscultated at the second right intercostal space and radiates to both carotid arteries.
Which one of the following is the most likely diagnosis?

A 55-year-old woman with interstitial lung disease is evaluated for exertional dyspnea and bilateral lower extremity swelling. On exam, she has elevated jugular venous pressure with prominent v-wave. The liver is pulsatile and palpable. A left parasternal heave is present. On cardiac auscultation, the pulmonic component of S2 is accentuated.
Which of the following is the most likely additional finding on cardiac auscultation?

A 71-year-old man with hypertension presents to the emergency department with palpitation for several hours. On arrival, vital signs show irregularly irregular pulse of 140 bpm and blood pressure of 170/100 mmHg. An echocardiogram shows left ventricular hypertrophy with normal ejection fraction and no atrial thrombus.
Which of the following is the most common cause of death in this patient?

A 45-year-old woman presents to the clinic for annual health examination. She is asymptomatic. On physical examination, vital signs show blood pressure of 144/92 mmHg. A repeat measurement after 5 minutes of rest is 142/90 mmHg. The remainder of her examination is unremarkable.
Which one of the following is the most appropriate next step in management?

A 68-year-old woman with diabetes presents to the clinic for routine follow-up. She reports no symptoms. Her blood pressure is 165/92 mm Hg and heart rate of 61 bpm. Physical examination and laboratory studies are unremarkable. Urinalysis reveals proteinuria 1+ on dipstick.
Which one of the following is the most appropriate next step in management?

A 22-year-old male presents to the emergency department with palpitation. Vital signs show heart rate of 170 bpm, blood pressure of 110/80 mm Hg, respiratory rate of 20 bpm, and oxygen saturation of 96% on room air. Physical examination is within normal limits. An ECG reveals supraventricular tachycardia.
Which one of the following is the most appropriate next step in management?

A 72-year-old woman with diabetes, hypertension, and ischemic heart disease presents with dyspnea over the past 48 hours. She reports that her breathing difficulty worsens within 10–15 minutes of lying flat and improves after sitting upright. She denies chest pain or palpitations. Vital signs are within normal limits. An ECG reveals no changes. Chest X-ray demonstrates bilateral pulmonary interstitial infiltrates.
Which one of the following is the most likely cause of patient's symptoms?

A 64-year-old woman with diabetes presents to the emergency department with substernal chest pain radiating to her jaw. Vital signs show blood pressure of 85/50 mmHg. Physical examination reveals jugular venous distention, clear lung bilaterally, and no lower extremity edema. The ECG demonstrates ST-segment elevations in leads II, III, and aVF.
Which of the following is the most likely diagnosis?

A 63-year-old man with hypertension and diabetes presents to the emergency department with acute chest pain. Vital signs show blood pressure of 115/80 mm Hg, heart rate of 84 bpm, and respiratory rate of 16 bpm. An ECG reveals ST-segment elevation in leads II, III, and aVF.
Which one of the following is the most appropriate next step in management?

A 70-year-old man undergoes partial gastrectomy for gastric adenocarcinoma. Four days later, he develops retrosternal chest pain. His blood pressure is 120/70 mmHg, heart rate 78 bpm, respiratory rate 16 bpm, and oxygen saturation 95% on room air. Cardiac auscultation reveals prominent S4 gallop. An ECG demonstrates ST-segment elevations in leads V2–V5. Aspirin, clopidogrel, and sublingual nitrates are initiated.
Which one of the following is the most appropriate next step in management?

A 66-year-old man with hypertension and diabetes presents to the emergency department with substernal chest pressure that began 20 minutes ago. The pain radiates to his left shoulder and is not relieved by rest. An ECG shows ST-segment depression in leads V2–V5, and initial troponin levels are elevated.
Which one of the following is the most likely diagnosis?

A 62-year-old man with diabetes presents to the emergency department with acute substernal chest pain. An ECG reveals ST-segment elevations in leads II, III, and aVF. He receives aspirin, nitroglycerin, and morphine. Thirty minutes later, while awaiting transfer to the catheterization, the patient develops sudden hypotension, tachycardia, and tachypnea. Chest is clear bilaterally.
Which of the following is the most likely cause of his acute deterioration?

A 60-year-old man with hypertension treated with hydrochlorothiazide presents for routine follow-up. He reports no chest pain, dyspnea, or syncope. Blood pressure is 138/86 mm Hg. Cardiac auscultation reveals 2/6 mid-systolic murmur at the right upper sternal border that radiates toward the carotid arteries. There is prominent S4 at the apex. No S3 or diastolic murmur is heard.
Which of the following is the most likely diagnosis?

A 65-year-old male with asthma and ischemic heart disease reports worsening dyspnea on exertion over the past 4 weeks. On cardiovascular examination, grade 4/6 murmur is best heard at the right upper sternal border. Lungs are clear to auscultation bilaterally. There is no jugular venous distension or peripheral edema.
Which of the following is most appropriate imaging study to confirm the diagnosis?

A 36-year-old man presents to the clinic for follow-up visit. He is diagnosed with hypertension three months ago. He was counseled on lifestyle modifications, including dietary sodium reduction and regular aerobic exercise. Today, his blood pressure is 145/80 mm Hg. A laboratory workup is unremarkable.
Which one of the following is the most appropriate first-line medication to prescribe?

A 32-year-old man with no significant medical history presents for routine checkup. He is asymptomatic. His vital signs are stable. Cardiac auscultation reveals high-pitched, decrescendo diastolic murmur heard best at the left lower sternal border. Palpation of the femoral arteries reveals pistol-shot pulse.
Which of the following is the most likely diagnosis?

A 68-year-old man presents to the clinic with several-month history of shortness of breath. He has 35-pack-year smoking history. Vital signs are within normal limits. On exam, he has jugular venous distension and 3+ bilateral pitting edema.
Which one of the following is the most likely diagnosis?

A 41-year-old man presents to the emergency department with two-day history of sharp chest pain. His vital signs show blood pressure of 135/80 mm Hg, heart rate of 112 bpm, and respiratory rate of 22 bpm. On auscultation, chest is clear bilaterally with pericardial friction rub. An ECG reveals diffuse ST-segment elevation in all leads.
Which one of the following is the most appropriate next step in management?

A 67-year-old man with diabetes and poorly controlled hypertension presents for routine follow-up. For the past year, he reports stable exertional chest tightness lasting approximately 5 minutes, relieved by rest. His current medications include insulin, enalapril, and sublingual nitroglycerin. Vital signs show blood pressure of 144/92 mm Hg.
Which one of the following medications is most appropriate to add to his regimen?

A 45-year-old patient is evaluated for recurrent episodes of dizziness. He has ejection systolic murmur best heard at the left sternal border which increases with standing. Echocardiography reveals left ventricular enlargement.
Which one of the following is the most likely diagnosis?

A 67-year-old man with diabetes and hypertension presents to the emergency department with worsening shortness of breath over the past week. On exam, he has bibasilar crackles, jugular venous distension, abdominal distension, hepatomegaly, and bilateral pitting edema up to the ankles. An echocardiogram reveals reduced left ventricular ejection fraction of 40%.
Which one of the following is the most appropriate next step in management?