A 63-Year-Old Man With Diabetes and Coronary Artery Disease

A 63-year-old man is referred to your clinic for evaluation of chest pain. He reports several weeks of exertional chest tightness associated with mild shortness of breath when he is mowing the lawn. These symptoms never occur at rest. He has a history of type 2 diabetes and hypertension.

He has no significant family history. He has a ten pack year smoking history and quit smoking twenty-five years prior. His medications include metformin 1000 mg twice daily, lisinopril 10 mg daily, aspirin 81 mg daily, and hydrochlorothiazide 25 mg daily.

His blood pressure is 139/87 mm Hg with a pulse of 75 beats per minute (bpm) and a body mass index (BMI) of 31. His exam is notable for slightly diminished dorsalis pedis and posterior tibial pulses with normal lower extremity perfusion and no edema. Exam was otherwise unremarkable.

His electrocardiogram (ECG) shows normal sinus rhythm at 83 bpm, and criteria for left ventricular hypertrophy with nonspecific ST and T-wave changes.

His laboratory values are significant for HbA1c 8.4%, total cholesterol 227 mg/dL, high-density lipoprotein cholesterol (HDL-C) 37 mg/dL, triglycerides 255 mg/dL, low-density lipoprotein cholesterol (LDL-C) 142 mg/dL, TSH of 1.3 mIU/L and serum creatinine of 1.1 mg/dL.

Figure 1
Figure 1: Perfusion images

Given his symptoms, coronary disease risk factors and ECG changes, he undergoes a one-day exercise Tc-99m myocardial perfusion study. He exercises a total of seven minutes, 49 seconds on a standard Bruce protocol and achieves 9.8 METS. Peak heart rate is 135 bpm (86% of his maximum predicted heart rate). He develops mild chest pain with peak exercise, and the test is terminated due to leg fatigue. At peak stress, his ECG exhibits 1 mm horizontal ST depressions in the inferior leads that resolve two minutes into recovery. Perfusion images are shown (Figure 1).

In addition to intensifying his glycemic control and adding a statin, which of the following is the next best step in this patient's management?

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