Management of Stable Angina in Patients with Multivessel CAD and Diabetes

A 68-year-old obese male patient with a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus was referred to you by his primary care physician for further evaluation of progressively worsening chest discomfort and dyspnea, which have been present over the past few months. Both symptoms initially were brought on after walking up 3 flights of stairs but now are elicited with minimal exertion such as walking 100 feet. His symptoms resolve with rest. He states he does not routinely exercise but is active at his job as a construction worker. He has a 1-pack-per-day smoking history; he quit a few months ago because he attributed his exertional symptoms to his tobacco use.

His home medications include low-dose aspirin, high-dose rosuvastatin, lisinopril, and a long-acting nitrate. His blood pressure is 122/78 mmHg, and heart rate is 60 bpm. His last hemoglobin A1c was 7. An electrocardiogram in your office reveals normal sinus rhythm with an old left bundle branch block. An echocardiogram reveals a left ventricular ejection fraction of 40% with anterior, anteroseptal, and inferoseptal wall hypokinesis. Consequently, he undergoes an exercise nuclear stress test that reveals a moderately large reversible perfusion defect involving the anterior, anteroseptal, and inferoseptal myocardium. Coronary angiography shows an 80% occlusion of his mid left anterior descending (LAD) artery, a 95% occlusion of the first proximal obtuse marginal artery, and a 75% occlusion of the proximal posterior descending artery (PDA) with a dominant right coronary artery.

After discussing the angiographic findings with the patient, what is the best next step?

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