Return to Play Post-Myocardial Infarction
A 60-year old male is seen in clinic to discuss returning to competitive distance running. Three months prior, he suffered ventricular fibrillation cardiac arrest while training for a marathon. After resuscitation in the field, emergent coronary angiography revealed a culprit 95% proximal left anterior descending artery lesion, for which he received a drug eluting stent. Angiography also revealed a 60-70% mid right coronary artery (RCA) stenosis (FFR 0.82), which was not revascularized. In the interim, he successfully completed cardiac rehabilitation with a graded exercise program. Without consulting with a physician, he resumed running 3-4 miles several days per week without angina, dyspnea, dizziness or syncope. His medications include atorvastatin, aspirin, prasugrel, and ramipril. Resting ECG is shown (Figure 1). Angiography of the RCA lesion is shown (Figure 2). Echocardiography revealed a normal left ventricular ejection fraction (LVEF) of 60%, without segmental wall motion abnormalities or valvular pathology. He would like to discuss resuming training for a marathon.
In addition to optimal medical therapy, which of the following is the most appropriate next step in management?