Secondary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults

An active 79-year-old man develops new-onset substernal chest tightness while playing golf. He has to sit on the ground for the pain to subside. As a result, he avoids his usual daily walk around the golf course. While he remains independent in all activities of daily living, he reports an increase in his weight (body mass index [BMI] = 28 kg/m2). Otherwise, he was never hospitalized in the past 12 months and rates his health as "very good." He takes atenolol 50 mg and aspirin 81 mg on daily basis. He has a history of isolated systolic hypertension, but no history of chronic lung disease, cancer, or congestive heart failure. He has a remote history of smoking, but quit "many years ago." He has no memory problems and still manages his finances.

You order a stress electrocardiogram (ECG) with imaging, which shows diffuse ST-segment depression in the anterolateral leads at peak exercise. His stress echocardiographic images demonstrate anterolateral wall motion abnormalities of moderate severity. A follow-up coronary angiography showed a chronic total occlusion of the right coronary artery and severe diffuse disease in the left anterior descending artery that is not amenable to percutaneous or surgical intervention. He comes back to the clinic for follow-up.

Which of the following describes the next best step in the management of this patient?

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