A 68-year-old Native American housewife who lived on an Indian reservation in Nevada had been under the care of a family practice physician for congestive heart failure (CHF). She had had an acute myocardial infarction (MI) 4 years ago. Left ventricular failure was first noted 18 months ago, and the patient was kept in a compensated state on multidrug therapy until 10 weeks ago when her CHF did not respond to her current regimen. Her medications included digoxin 0.125 mg daily, furosemide 40 mg twice a day, enalapril 20 mg every morning, carvedilol 25 mg twice a day, atorvastatin 20 mg every night at bedtime, ezetimibe 10 mg every night at bedtime, and a salt-poor diet. Physical examination revealed the following: fine moist rales were heard in the right base, there was an S3, S4,...

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