Heart Failure USMLE Step 1 Practice Question

A 62-year-old woman with a 10-year history of hypertension presents to the emergency department with progressive dyspnea on exertion over the past 3 months, orthopnea requiring 3 pillows at night, and lower extremity edema. She denies chest pain or palpitations. Vital signs show BP 158/92 mmHg, HR 98 bpm, RR 22/min, and oxygen saturation 94% on room air. Physical examination reveals bilateral crackles at the lung bases, a laterally displaced point of maximal impulse, an S3 gallop, and elevated jugular venous pressure at 8 cm H2O. Basic metabolic panel shows Na 138 mEq/L, K 4.2 mEq/L, and Cr 1.0 mg/dL. Chest X-ray demonstrates pulmonary edema. Transthoracic echocardiography shows a left ventricular ejection fraction of 35% with global hypokinesis and no significant valvular disease. Which of the following is the most appropriate initial pharmacologic management strategy?