A 52-year-old woman with dilated cardiomyopathy presents to the ICU with acute decompensated heart failure. Vital signs: BP 88/54 mmHg, HR 122/min, RR 24/min, SpO2 90% on 4L nasal cannula. Laboratory studies reveal BNP 920 pg/mL, creatinine 1.8 mg/dL (baseline 0.9), and lactate 2.1 mmol/L. Transthoracic echocardiography shows ejection fraction of 20% with global hypokinesis. The patient receives intravenous milrinone for inotropic support. Two hours later, her cardiac output increases from 3.2 to 4.1 L/min, but her systolic blood pressure decreases to 78 mmHg and systemic vascular resistance drops from 1400 to 800 dyne·sec·cm⁻⁵. Urine output remains adequate at 0.5 mL/kg/hr. Which of the following agents should be added to maintain adequate organ perfusion pressure while preserving the inotropic benefit of milrinone?

1. A)Esmolol, to reduce tachycardia and myocardial oxygen demand without altering systemic resistance
2. B)Norepinephrine, to provide alpha-adrenergic vasoconstriction and maintain perfusion pressureGABARITO
3. C)Dobutamine, to enhance inotropic effect and counteract milrinone-induced hypotension
4. D)Hydralazine, to reduce afterload and optimize ventricular function in cardiomyopathy
5. E)Dopamine at low dose, to increase renal perfusion and prevent acute kidney injury