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Answer 4
  1. He should receive carvedilol once he is stable (preferably as an outpatient). Carvedilol is a non-selective beta-blocker with additional peripheral vasodilating properties (through alpha-blockade) and is approved for use in patients with CHF. Carvedilol therapy should not be initiated at the time of hospital admission, when the patient is decompensated; rather, the optimum time is when the patient is stable, following adequate diuresis. Treatment is begun with small doses of carvedilol, typically 3.125 mg twice daily, and gradually titrated upward to a maximum dose of 25 mg twice daily. The systolic blood pressure of 100 mm Hg and the low ejection fraction are not contraindications to carvedilol therapy; both should improve with therapy.

     Consensus recommendations for the management of chronic heart failure. On behalf of the membership of the advisory council to improve outcomes nationwide in heart failure. Am J Cardiol 1999;83:1A-38A.

    2. Gomberg-Maitland M, Baran DA, Fuster V. Treatment of congestive heart failure: guidelines for the primary care physician and the heart failure specialist. Arch Intern Med 2001;161:342-52.

    3. Heart failure. In: Arky RA, Kettyle WM, Hatem CJ, editors. MKSAP 12: Cardiovascular medicine. Philadelphia: American College of Physicians - American Society of Internal Medicine; 2001:38-49.

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