A 63-year-old black man with a history of essential hypertension, diabetes mellitus type II, atherosclerotic heart disease, and osteoarthritis presented to the emergency department with generalized edema and orthopnea. He had been examined periodically in recent months because of progressive congestive heart failure (CHF) and peripheral edema. Increasing doses of diuretics and a sodium-restricted diet failed to be effective. Current treatment consisted of furosemide 60 mg 2 times a day, potassium supplements, digoxin 0.25 mg daily, enalapril 10 mg daily, slow-release metformin 1000 mg daily, and a low-sodium, low-carbohydrate, cholesterol-poor diet. In addition, the patient had been taking ibuprofen for chronic osteoarthritis. Despite compliance with his medications, he noticed progressive weakness, fluid retention, frequent attacks of paroxysmal nocturnal dyspnea, and an inability to perform minor tasks around the house. He denied having any chest pains or palpitations.

Physical examination revealed a dyspneic patient with anasarca and prominent jugular venous distention...

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