5th May 2025

Mr Patel is a 73-year-old gentleman with a past medical history of ischaemic heart disease, congestive cardiac failure (ejection fraction 40%), hypertension, type 2 diabetes mellitus and hypercholesterolemia.

Mr Patel is a 73-year-old gentleman with a past medical history of ischaemic heart disease, congestive cardiac failure (ejection fraction 40%), hypertension, type 2 diabetes mellitus and hypercholesterolemia. He has a right ventricular pacemaker inserted for SND 5-years ago. At his routine follow-up in clinic, you note he is short of breath walking from the waiting area into the consultation room. On asking, he discloses struggling with daily activities and increasing ankle swelling. He denies any chest pain, syncope or palpitations. On examination, you notice bi-basal coarse crackles at the lung bases with mild pitting oedema to the knees bilaterally. The remainder of the physical examination is unremarkable. His GP recently increased his diuretics, to little effect. What would be the next most appropriate step in his management? 

Select the SINGLE most appropriate option from the list below. Select ONE option only.