82-year-old male, with a history of HTN, HLD, and CAD, presents to your clinic with a six-month history of dyspnea on exertion.  He states he is unable to walk as far as he used when exercising, and when he over exerts himself, he reports having some mild chest pain and feeling lightheaded.  This resolves with rest and he denies any syncope with these events.

Medications

Metoprolol 50mg daily

Lisinopril 10mg daily

Simvastatin 30mg daily

Vital Signs

BP – 158/97

HR – 62

RR – 13

O2% – 100%

Physical exam

General – WN/WD male in NAD

Pulmonary – CTA without adventitial breath sounds

CV – Soft S2 with murmur over right 2nd intercostal space

PV – carotid pulse is weak and has a slow rise, murmur is appreciated

Neuro – No focal deficits

EKG

Questions

1. What is the next step in the management of this patient?
2. After the next step, what important variables must you specifically assess?