Approach to hypertension Quiz: Ace Your Exams

A 77-year-old man with a history of coronary artery disease presents to the emergency department for evaluation of two days of worsening shortness of breath. He has noticed decreased urine output. He has not had fevers, chest pain, or recent travel. Additional past medical history is significant for hypertension for which the patient takes amlodipine. He was also started on lisinopril two weeks ago. The patient has a 40 pack-year smoking history. Temperature is 36.8°C (98.2°F), blood pressure is 190/100 mmHg, pulse is 102/min, respiratory rate is 22/min, and oxygen saturation is 90% on room air. Physical examination reveals rales at the bilateral lung bases and an S4 heart sound. There is bilateral lower extremity pitting edema to the mid calves without overlying erythema. Laboratory findings are significant for an increase in serum creatinine level from 1.2 to 2.2 mg/dL over the past two weeks (reference range: 0.6-1.2 mg/dL). Urinalysis reveals mild proteinuria. Chest X-ray is significant for bilateral pulmonary edema. Which of the following is the most likely diagnosis?