Best Medications to improve Ejection Fraction in Testosterone Users?

It turns out I had crazy high blood pressure (170/100), likely for months, too much caffeine, stress and I'm 125kg/275 pounds / 192cm/6'4, 44 years old.

Last week a cardiologist put me on Dipperam 5+160 (5mg Amlodipine + 160mg Valsartan), using this first once a day and after 2 days moved on to twice a day, which puts me around 127/78 after 1 week.
The maximum effect comes around 3-4 weeks, so I should soon be at 120 or below with that.

The cardiologist also sent me to have a ultrasound heart analysis by another doc, who found my heart Ejection Factor is only 48% (normal: 50-70) and I have some left ventricle hypertrophy (38mm). The doc commented that for my age (44 years old), 48% is way too low and this must be looked at.

I have been reading a lot on the topic and came to the conclusion that Nebivolol might be the best option to help with Ejection Factor, in general, this seems the beta blocker with the least negative side effects and potential positives (increase in NO, antioxidant profile, reduction of glucose, reduction of heart rate, etc.), a 10% increase seems likely with only 3 months at 5mg / day, and the left ventricle hypertrophy may also be reversed:
after 3 months of orally administered nebivolol (2.5 and 5 mg, n = 6)
[...]
Left ventricular function increased (ejection fraction 31.5 +/- 10.11 to 42.0 +/- 10.99%, P < or = 0.01) after 12 weeks of nebivolol. The left ventricular end-systolic diameter decreased in the nebivolol-group from 56.5 +/- 9.40 to 50.2 +/- 9.43 mm (P < or = 0.02).
From: Effect of nebivolol on left ventricular function in patients with chronic heart failure: a pilot study - PubMed

I also found this YouTube Video really interesting:

Coach Steve's Experience with Nebivolol; Heart Rate, Blood Pressure & Fat Loss. Vigorous PEDs​

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Questions:

1. Is Nebivolol one of the best options to [ improve Ejection Factor + reduce left ventricle hypertrophy ] OR is there something better with low potential for negative side effects?
2. Should I just add Nebivolol to the already working "5mg Amlodipine + 160mg Valsartan" combo, or should I try to get rid of Amlodipine if blood pressure starts to go too low?
3. Depending on blood pressure numbers, would Nebivolol + Telmisartan be a good option once I lose some fat? (10kg/20lbs should result in a ~20 point blood pressure reduction in my case, but this will take at least 3 months, trying to minimize muscle loss)
4. Would Doxazosin be comparable to Nebivolol to improve Ejection Factor & reduce left ventricle hypertrophy?

Other clarifications for additional background:

Some life style notes: no coffee or caffeine in the last 2 weeks (lots of this before), magnesium: 500mg @ morning + 700mg @ night, citrulline malate here & there, trying to do hot baths (1h x 3 times / week after weight training) due to no sauna, 45min static bike x3 times a week, weight lifting 3 days / week.

My TRT protocol:
200mg weekly (real dose ~170mg or less due to ampule extraction, loss in injections, etc.)
2 injections: MF, 100mg each (likely ~80-90 max)
hCG in the same injection
Anastrozole 2mg / week, 1mg on injection day (This would be high for most people but seems to work well for me, otherwise my E2 goes too high)
Daily cialis: 10mg, now testing 5mg morning + 5mg evening
Common supplements: Creatine, Pregnenolone, DHEA, Boron, Vitamin D3+K2, desiccated beef organs

Recent labs:
Total T: 967.9
Free T: 32.41
E2: 42.6
Ferritin: 50ng/ml

 

Do you exercise? cardio? weights? how do all these medications effect your energy levels. I simply cannot tolerate Nebivolol. Its makes me sleepy

Apologies once again for the huge delay!

I exercise with weights
cardio is limited to walking on a walking pad + hiking on weekends, I should do more in this area.

In general, I have good energy levels and nebivolol makes me less reactive, more "zen", and given my usual stress levels this is a good thing xD.

Here's another update & some new blood work highlights:
Attaching recent blood work.

1) @Nelson Vergel HDL is 55, without niacin, just Telmisartan & protocol below.
2) GFR via cistatin C formula is 140+, so excellent.
3) CoQ10, without supplementing it, just using Beef Heart Powder, etc. is at 5.1, > x2 the MAX range
4) Liver enzymes could be better, but look OK
5) BP was 119/81 on 2025-04-01, pulse at rest 66
6) Weight: 107kg
7) I had a CT scan: My arteries are at 20, which puts me ahead of 98.6% of the population for my age (46) and gender. Maybe the daily Pomegranate juice has something to do with this, speculative.

My EF is now perfect: consistently measured around 63-68 by several cardiologists, i.e. EF - 63.8% 2024-03-19

This is using the protocol, where I accepted readalot's challenge and I've been at > 250mg / week for > 2 years now.

Updated TOT Protocol:
Testosterone Enanthate @ ~250mg / week, injecting ~80-90mg x 3 / week MWF [ ~250mg/week is the real injected amount, based on my math on ampule loss, injection loss, the fact I get at least 2 extra shots when I preload syringes, etc. ]
HCG @ ~390 IU x 3 week MWF
Anastrozol @ 1mg/week MW [ because my E2 runs too high otherwise, even at lower 140mg/week doses, my bone density is off the charts due to weight training ]
Update: I lowered Anastrozole from 2mg/week to 1 mg/week MW, due to lowish E2, I'm trying to live with higher E2, to improve my HDL Cholesterol further (already pretty good at 55)

Current Supplements & Meds:
- 1/day x Temilsartan 80mg [ for BP, HCT, lipids, etc. stay tuned for blood work ]
- 2/day x Nebivolol 5mg [ for BP & HR, NO gastric reflux ]
- 1/day x Doxazosin 4mg [ for BP, 1 dose, evening only ~18:30 ]
- 2/day x Cialis 5mg [ for many reasons ]
- 2/day x TUDCA 1200 mg [ -30 points in Liver markers ALT, ASP ]
- 1/day x 100mg DHEA [ because DHEA was low in blood work ]
Update: NO omega3 supplementation
Other things:
Citrulline Malate [ for NO ]
Electrolites [ for fasting days ]
MCT C8 Oil [ for first 2 fasting days / week, to ease the transition to Keto ]

Other things Before bed:
1 x B complex [ always ]
1 x 50mg pregnenolone [ always ]
1 x 3mg boron [ always ]
~3h before bed: 900mg Magnesium Citrate

From nutriest.eu (EU supplier for carnivore-based supplements, to avoid customs), I take:
Beef heart powder, Beef kidney powder
^ in my morning shake, which also has 60g of whey, 5g creatine

Since I pre-load my BP meds into small morning & evening glass recipients, I put more nutriest stuff in these:
Beef testicles, which also has oysters and other things
Beef brain

In general, I feel pretty good, mentally sharp, would like to drop a bit more fat, but all seems OK.

Additionally, I recently had a septoplasty surgery, to improve nose breathing and hopefully reduce snoring, I'm told results will be noticed 1 month after the surgery, so fingers crossed

 

Apologies once again for the huge delay!

I exercise with weights
cardio is limited to walking on a walking pad + hiking on weekends, I should do more in this area.

In general, I have good energy levels and nebivolol makes me less reactive, more "zen", and given my usual stress levels this is a good thing xD.

Here's another update & some new blood work highlights:
Attaching recent blood work.

1) @Nelson Vergel HDL is 55, without niacin, just Telmisartan & protocol below.
2) GFR via cistatin C formula is 140+, so excellent.
3) CoQ10, without supplementing it, just using Beef Heart Powder, etc. is at 5.1, > x2 the MAX range
4) Liver enzymes could be better, but look OK
5) BP was 119/81 on 2025-04-01, pulse at rest 66
6) Weight: 107kg
7) I had a CT scan: My arteries are at 20, which puts me ahead of 98.6% of the population for my age (46) and gender. Maybe the daily Pomegranate juice has something to do with this, speculative.

My EF is now perfect: consistently measured around 63-68 by several cardiologists, i.e. EF - 63.8% 2024-03-19

This is using the protocol, where I accepted readalot's challenge and I've been at > 250mg / week for > 2 years now.

Updated TOT Protocol:
Testosterone Enanthate @ ~250mg / week, injecting ~80-90mg x 3 / week MWF [ ~250mg/week is the real injected amount, based on my math on ampule loss, injection loss, the fact I get at least 2 extra shots when I preload syringes, etc. ]
HCG @ ~390 IU x 3 week MWF
Anastrozol @ 1mg/week MW [ because my E2 runs too high otherwise, even at lower 140mg/week doses, my bone density is off the charts due to weight training ]
Update: I lowered Anastrozole from 2mg/week to 1 mg/week MW, due to lowish E2, I'm trying to live with higher E2, to improve my HDL Cholesterol further (already pretty good at 55)

Current Supplements & Meds:
- 1/day x Temilsartan 80mg [ for BP, HCT, lipids, etc. stay tuned for blood work ]
- 2/day x Nebivolol 5mg [ for BP & HR, NO gastric reflux ]
- 1/day x Doxazosin 4mg [ for BP, 1 dose, evening only ~18:30 ]
- 2/day x Cialis 5mg [ for many reasons ]
- 2/day x TUDCA 1200 mg [ -30 points in Liver markers ALT, ASP ]
- 1/day x 100mg DHEA [ because DHEA was low in blood work ]
Update: NO omega3 supplementation
Other things:
Citrulline Malate [ for NO ]
Electrolites [ for fasting days ]
MCT C8 Oil [ for first 2 fasting days / week, to ease the transition to Keto ]

Other things Before bed:
1 x B complex [ always ]
1 x 50mg pregnenolone [ always ]
1 x 3mg boron [ always ]
~3h before bed: 900mg Magnesium Citrate

From nutriest.eu (EU supplier for carnivore-based supplements, to avoid customs), I take:
Beef heart powder, Beef kidney powder
^ in my morning shake, which also has 60g of whey, 5g creatine

Since I pre-load my BP meds into small morning & evening glass recipients, I put more nutriest stuff in these:
Beef testicles, which also has oysters and other things
Beef brain

In general, I feel pretty good, mentally sharp, would like to drop a bit more fat, but all seems OK.

Additionally, I recently had a septoplasty surgery, to improve nose breathing and hopefully reduce snoring, I'm told results will be noticed 1 month after the surgery, so fingers crossed

 

That seems like a monster dose of T. I would be on a lot of BP meds if I took that much....

 

To the original question, Meldonium may be an option. I'm not sure TRT at moderate doses is relevant.