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A 71-Year-Old Man Comes to the Physician for Routine Evaluation

question 219

Multiple Choice

A 71-year-old man comes to the physician for routine evaluation. He has no symptoms and considers himself healthy. He walks several miles a day and jogs twice a week for 5 miles. The patient has no history of chest pain or syncope. Five years ago he had inguinal hernia repair without complications. His father died at age 90 of "old age" and his mother died of breast cancer. He has never smoked.
His blood pressure is 126/70 mm Hg and pulse is 72/min and regular. He has no jugular venous distension when sitting. The apical impulse is displaced to the left. A 2/6 holosystolic murmur is heard at the apex. The lungs are clear, and there is no organomegaly. The pulses are full bilaterally and there is no peripheral edema. ECG shows normal sinus rhythm with abnormal Q waves in leads V2 to V4. Transthoracic echocardiography shows left ventricular enlargement, anterior wall and apical akinesis, and left ventricular ejection fraction of 35%. There is mild mitral regurgitation. He declines coronary angiogram.
Which of the following is the best next step in management of this patient?

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