A 72-Year-Old Man with a History of Heart Failure and Reduced

question 730

Multiple Choice

A 72-year-old man with a history of heart failure and reduced ejection fraction comes to the office for follow-up.  The patient reports no change in his chronic dyspnea on exertion but says he has had a persistent, nonproductive cough for the past 4 weeks.  The cough occurs during the day and night, and he has not been able to get restful sleep.  The patient has had no fever, chills, night sweats, or loss of appetite.  In the past year, he has had several hospitalizations due to decompensated heart failure, and 6 months ago he was treated with coronary stenting for an episode of non-ST elevation myocardial infarction.  A recent echocardiogram revealed a left ventricular ejection fraction of 30%.  The patient's other medical problems include hypertension, hyperlipidemia, and osteoarthritis.  He takes aspirin, ticagrelor, atorvastatin, furosemide, carvedilol, sacubitril-valsartan, and spironolactone.  He smoked a half pack of cigarettes daily for 10 years, but quit at age 40.  The patient does not use alcohol or illicit drugs.
Temperature is 36.6 C (98 F) , blood pressure is 106/60 mm Hg, pulse is 72/min and regular, and respirations are 16/min.  Pulse oximetry shows 96% on ambient air.  Weight is 75 kg (165.3 lb) , unchanged from previous visits.  Physical examination reveals normal nasal and oropharyngeal mucous membranes, poor dentition, normal jugular venous pressure, clear lungs, and a grade 2/6 systolic murmur at the left sternal border.  The abdomen is soft and nontender with no hepatosplenomegaly.  Trace bilateral lower extremity pitting edema is present.
Chest x-ray reveals no parenchymal opacities.
Which of the following is the most appropriate next step in management of this patient?

• A)Discontinue sacubitril
• B)Increase furosemide
• C)Obtain CT scan of the chest
• D)Perform pulmonary function testing
• E)Prescribe a trial of proton pump inhibitor