A 63-year-old man with ty...

A 63-year-old man with type 2 diabetes and hypertension seeks assessment for chest pain. He reports experiencing tightness in his chest during physical activities like mowing the lawn, accompanied by mild shortness of breath, though these symptoms do not occur while at rest. He has a smoking history totalling ten pack-years, having quit 25 years ago, and lacks a significant family history of cardiovascular conditions. His current medications include metformin 1000 mg twice a day, lisinopril 10 mg daily, aspirin 81 mg daily, and hydrochlorothiazide 25 mg daily. Physical examination reveals a blood pressure of 139/87 mm Hg, a pulse rate of 75 bpm, and a BMI of 31. His dorsalis pedis and posterior tibial pulses are somewhat diminished, but his lower extremities show normal perfusion without swelling. The ECG demonstrates a normal sinus rhythm at 83 bpm, left ventricular hypertrophy, and non-specific changes in ST and T-waves. Laboratory results indicate an HbA1c of 8.4%, total cholesterol of 227 mg/dL, HDL cholesterol of 37 mg/dL, triglycerides of 255 mg/dL, LDL cholesterol of 142 mg/dL, TSH of 1.3 mIU/L, and serum creatinine of 1.1 mg/dL. How would you approach the differential diagnosis, and what would be your next steps in managing his cardiovascular risk?