A 56 year-year-old male was referred
to you with progressive easy fatigueability, moderate exertional dyspnea
and two pillow orthopnea of a 1 year duration.
Relevant physical findings include BP 104/64 mm Hg,
pulse 104/min and unlabored repirations at 20/min. Neck veins are engorged
3 cm above the clavicle at 30 degrees and the abdomino-jugular (also
referred to as hepato-jugular) reflux is positive. The apical impulse
is located two cm lateral to the left mid-clavicular line in the 6th
interspace. Soft S3 and S4 gallops together with a grade 2/6 holosytolic
murmur are heard at the apex. There are bibasilar inspiratory rales
and 2+ pitting edema of the legs.
Chest x-ray reveals moderate cardiomegaly with pulmonary
congestion. EKG shows a sinus mechanism with a CLBBB and frequent unifocal
premature ventricular contractions. Echocardiography reveals a left
ventricular end-diastolic dimension of 62 mm with global hypokinesia,
EF of 38% and moderate MR. The inferior vena cava is moderately distended
and demonstrates poor inspiratory collapse
Which ONE of the following is initially indicated in the management
of this patient?