Medical Therapy for Coronary Artery Disease
A 60-year-old man with known chronic coronary artery disease (CAD) is referred to you because of an abnormal stress test. He has a history of angina beginning 3 years ago, at which point he had coronary angiography. This demonstrated a 60% mid-left-interior-descending stenosis (Figure 1) and fractional flow reserve of 0.85. He had other lesions in the right coronary artery and circumflex artery that were less than 50%. It was elected to treat him medically at that time, and his antianginal medications were intensified. His angina abated, and he has been feeling well on medical therapy. He exercises 30 minutes 4-5 times per week with no limitations. He has presumed familial hypercholesterolemia; two of his children and one grandchild have significantly elevated lipids (low-density lipoprotein cholesterol [LDL-C] > 200 mg/dl). His father died of a myocardial infarction at age 50. The patient has hypertension but no history of diabetes mellitus, cigarette smoking, obesity, or sedentary lifestyle. His current medications include atorvastatin 80 mg, ezetimibe 10 mg, aspirin 81 mg, bisoprolol 10 mg, amlodipine 5 mg, and perindopril 8 mg, all daily.
He recently had an exercise stress test as part of an executive evaluation. He walked for 9 minutes on a Bruce protocol and achieved a maximum heart rate of 140 bpm and blood pressure of 155/70 mm Hg. He had no chest pain, and there was 1.5 mm ST depression in the third stage in his inferolateral leads. This recovered within 2 minutes of exercise cessation. He has a normal physical examination with a body mass index of 26 kg/m2. He has LDL-C of 3.5 mmol/L (135 mg/dl), high-density lipoprotein cholesterol of 1.1 mmol/L (42 mg/dl), glycated hemoglobin of 5.9%, and estimated glomerular filtration rate > 60 ml/min/1.73m2.
What feedback is appropriate for this gentleman at this time?