The ISCHEMIA Trial: An Illustrative Case

Case Background
A 57-year-old man presented to his cardiologist's office and reported a mild, pressure-like sensation in his chest during his daily workouts that resolves with rest. This symptom had been present for almost a year without significant change. He had a history of type 2 diabetes, hypertension, and hyperlipidemia. He had a non-ST-segment elevation myocardial infarction (MI) 3 years ago, for which he underwent percutaneous coronary intervention (PCI) of his right coronary artery. A 40% stenosis of his mid left anterior descending artery (LAD) was noted at that time. His current medications included carvedilol 12.5 mg twice daily, aspirin 81 mg once daily, atorvastatin 80 mg once daily, ramipril 2.5 mg once daily, and metformin 1,000 mg twice daily.

On examination, his temperature was 97.6 degrees F, heart rate was 78 bpm, blood pressure was 124/65, respiratory rate was 16, and oxygen saturation was 98% on room air. The remainder of his exam was unremarkable. An electrocardiogram showed normal sinus rhythm without any ischemic changes. Echocardiography showed a left ventricular ejection fraction of 50% and no regional wall motion abnormalities. An exercise nuclear stress test showed moderate ischemia in the LAD territory.

In light of available evidence, which of the following is true when counselling this patient?

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