Management of a Patient With SIHD and a CTO

A 78-year-old man with hypertension, hyperlipidemia, and history of smoking was referred to you by his primary care physician for further evaluation of substernal chest discomfort and dyspnea on exertion that has gradually developed over the last several months with no symptoms at rest. An electrocardiogram in the office revealed sinus rhythm with a left bundle branch block, which is chronic, and a corrected QT interval of 530 ms. On echocardiogram, left ventricular ejection fraction (LVEF) was 45% with anterior and anteroseptal wall hypokinesis. You ordered an exercise myocardial perfusion study, which showed a stress-induced perfusion defect involving 10% of the anterior and anteroseptal myocardium. He was then referred for coronary angiography, which revealed a chronic total occlusion (CTO) of his mid-left anterior descending (LAD) artery with grade 3 collaterals from a dominant right coronary artery. You decided to add a long-acting nitrate in addition to his home dose of beta-blocker and reassess his symptoms. He returned to your office 2 months later, now on highest tolerated doses of beta-blocker and nitrate limited by blood pressure with persistent angina.

What is the most appropriate next step?

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