A 43-year-old house painter is admitted because of progressive dyspnea, orthopnea and edema. He is alcoholic and has had one previous hospitalization for acute alcoholism. Physical Examination: BP 112/80, P 94+reg., R 24. Moderate signs of congestive failure with jugular venous distension, hepatomegaly, 2+ edema, and bilateral crackles. The heart border is 12 cm from the midsternal line with a diffuse sustained apical impulse. The following was heard on auscultation.