Increased Stressors in a Patient With Stable Coronary Disease

Editor's Note: Based on Mental Stress-Induced Myocardial Ischemia: An Underrecognized Cardiac Risk Factor?

The patient is a 64-year-old male with a history of hypertension, hyperlipidemia and coronary artery disease status post coronary artery bypass grafting two years prior with preserved left ventricular ejection fraction. He denies chest pain or shortness of breath. He has unlimited exercise tolerance. As he is about to complete his office visit, he mentions that over the prior six months, because of a poor economy, he has had to work longer hours, which has resulted in increased job stress. He is unmarried and lives alone. He denies depression.

His current medications currently include aspirin, metoprolol, lisinopril and atorvastatin.

His resting electrocardiogram is normal. An echocardiogram shows abnormal septal motion consistent with post-operative state, but otherwise a normal ejection fraction of 60-65% and no significant valvular abnormalities. Lipid panel includes total cholesterol 138 ml/dL, LDL-C 68mg/L, non-HDL-C 88 mg/dL, HDL-C 50 mg/dL, and triglycerides of 100 mg/dL. Blood pressure is 118/78, heart rate is 65 beats per minute. He is in no acute distress and his exam is unremarkable.

After further discussion of stressors, what is your next step in the management of this patient?

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