MRCP2-0367
A 78-year-old man presents to the emergency department with complaints of shortness of breath on exertion, difficulty walking up stairs, and significant weight gain over the last 2 weeks. His son who is with him expresses concerns about him and says that he is needing to lay upright in his armchair in order to get any sleep.
His medical history includes 2 previous non-ST-segment elevation myocardial infarctions for which he was treated with coronary stenting and hypertension.
Physical examination shows a heart rate of 111 beats per minute and blood pressure of 113/76 mmHg. He is visibly short of breath at rest and is using accessory muscles. His JVP is 7 cm above the angle of Louis, his apical impulse is laterally displaced, and heart sounds are audible with a holosystolic murmur heard loudest at the apex. Auscultation of his chest reveals audible crepitations bi-basally and he has 2+ peripheral oedema extending to his mid-thighs.
An ECG shows Q-waves in his inferior leads, and his bloods show elevated troponins.
What is the most appropriate next step in the management of this patient?