Hypertension And Vascular Disease - USMLE Step 3

1. A 72-year-old man with a 40-pack-year smoking history and type 2 diabetes presents with a 6-month history of cramping pain in his right calf that occurs after walking two blocks and is relieved by 5 minutes of rest. His ankle-brachial index is 0.65 on the right and 0.95 on the left. He is currently taking metformin and low-dose aspirin. In addition to counseling on smoking cessation and recommending a supervised exercise program, which of the following is the most appropriate addition to his medical regimen?
   Answer: Initiation of high-intensity statin therapy This patient has symptomatic peripheral artery disease (PAD). PAD is considered a coronary artery disease risk equivalent, and patients are at very high risk for myocardial infarction, stroke, and cardiovascular death. The cornerstone of medical management is aggressive cardiovascular risk factor modification. All patients with PAD should be on high-intensity statin therapy (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg) regardless of their baseline LDL-cholesterol level to reduce this risk. Cilostazol is used for symptom relief of claudication but does not reduce cardiovascular events. Dual antiplatelet therapy is not routinely recommended for stable PAD. Intervention is reserved for lifestyle-limiting symptoms refractory to medical therapy or for critical limb ischemia.
2. A 75-year-old woman is found to have a right carotid bruit on a routine physical exam. She has no history of stroke, transient ischemic attack, or amaurosis fugax. A carotid duplex ultrasound is performed and reveals an 80% stenosis of the right internal carotid artery. She is on optimal medical therapy for hypertension and hyperlipidemia, including aspirin, lisinopril, and atorvastatin. Which of the following is the most appropriate management for this patient?
   Answer: Continue current optimal medical therapy alone The management of asymptomatic carotid stenosis is controversial, and the benefit of intervention (carotid endarterectomy [CEA] or stenting) is small and diminishes with advanced age, particularly in women. The primary management strategy is optimal medical therapy, which includes antiplatelet agents (aspirin), high-intensity statins, and aggressive blood pressure control. Given her age, sex, and asymptomatic status, the risks of a perioperative stroke from CEA likely outweigh the potential benefits of stroke reduction compared to continuing medical therapy alone. Dual antiplatelet therapy is not indicated for stable, asymptomatic stenosis.
3. A 34-year-old woman presents with newly diagnosed hypertension. Her blood pressure is 170/105 mmHg. She has no family history of hypertension, a BMI of 22 kg/m², and does not use tobacco. On examination, a faint bruit is audible just to the right of the umbilicus. Initial laboratory studies, including serum electrolytes and creatinine, are within normal limits. Which of the following is the most appropriate next diagnostic test?
   Answer: CT angiography of the renal arteries The patient's presentation of severe, new-onset hypertension at a young age, particularly in a female, along with an abdominal bruit, is highly suspicious for secondary hypertension due to renal artery stenosis caused by fibromuscular dysplasia (FMD). FMD is a non-atherosclerotic, non-inflammatory vascular disease that most commonly affects the renal and internal carotid arteries. CT angiography or MR angiography of the renal arteries is the preferred non-invasive imaging modality to visualize the characteristic 'string of beads' appearance of FMD.
4. 70-year-old man with transient left arm weakness and 85% right ICA stenosis. What is the best long-term treatment?
   Answer: Carotid endarterectomy Transient left arm weakness is a right-hemisphere TIA, and with 85% right ICA stenosis this is symptomatic severe carotid disease. Best long-term treatment is carotid endarterectomy; it lowers recurrent stroke risk and is preferred over stenting in older patients. Carotid stenting is tempting but carries higher periprocedural stroke risk here, and dual antiplatelet therapy alone does not correct the stenosis.
5. A 62-year-old man with hypertension, type 2 diabetes, and stage 3 chronic kidney disease (eGFR 45 mL/min/1.73 m²) is managed with lisinopril 40 mg daily. His blood pressure is well-controlled at 125/75 mmHg. However, for the past three months, he has been bothered by a persistent, dry cough that occasionally wakes him at night. Which of the following is the most appropriate change to his medication regimen?
   Answer: Discontinue lisinopril and start losartan The patient is experiencing a classic ACE inhibitor-induced cough. This side effect is due to the accumulation of bradykinin and is not dose-dependent. Given his comorbidities of diabetes and chronic kidney disease, continued blockade of the renin-angiotensin-aldosterone system (RAAS) is indicated for its reno- and cardioprotective benefits. The most appropriate management is to switch from an ACE inhibitor (lisinopril) to an angiotensin II receptor blocker (ARB) like losartan. ARBs do not affect bradykinin levels and are therefore not associated with cough, while providing similar RAAS blockade benefits.
6. 64-year-old man with tearing chest pain, BP 212/112 mm Hg, and absent left radial pulse. What is the best next step?
   Answer: IV labetalol and CT Tearing chest pain with unequal pulses and hypertension is aortic dissection until proven otherwise. Start IV labetalol to lower heart rate and blood pressure immediately, then obtain CT angiography to define the dissection. Bedside ECG is the most tempting wrong answer because dissection can mimic MI, but it should not delay pressure control and imaging.
7. BP 172/106 mm Hg on 3 antihypertensive drugs including a diuretic; potassium normal. Which test is next?
   Answer: Aldosterone/renin ratio Resistant hypertension on three drugs including a diuretic makes primary aldosteronism the most common secondary cause to screen for, so the aldosterone/renin ratio is next even when potassium is normal. The 24-hour urine metanephrines is tempting because pheochromocytoma also causes resistant hypertension, but it is less common and not the routine first screen.
8. A 68-year-old asymptomatic man with a long history of smoking undergoes an abdominal ultrasound for evaluation of gallstones. The study incidentally identifies a fusiform infrarenal abdominal aortic aneurysm measuring 4.2 cm in maximal diameter. His blood pressure is 138/84 mmHg. Which of the following is the most appropriate surveillance recommendation for this finding?
   Answer: Repeat ultrasound surveillance in 12 months The management of abdominal aortic aneurysms (AAAs) is guided by their size. Elective repair is generally recommended for asymptomatic aneurysms ≥5.5 cm in men, or for those that demonstrate rapid expansion (>0.5 cm in 6 months or >1 cm in a year). For smaller aneurysms, surveillance with ultrasound is recommended. According to current guidelines, for an aneurysm measuring 4.0-4.9 cm, repeat ultrasound surveillance in 12 months is the appropriate interval. Surveillance every 6 months is for aneurysms 5.0-5.4 cm, and every 2-3 years is for those 3.0-3.9 cm.
9. 70-year-old man with diabetes, calf claudication, and ABI 1.45. What is the best next step?
   Answer: Toe-brachial index An ABI above 1.4 in a diabetic patient suggests calcified, noncompressible arteries, so ankle pressures can't be trusted. Toe arteries are less prone to calcification, making toe-brachial index the best way to assess distal perfusion. Exercise ankle ABI is tempting but still relies on falsely elevated ankle pressures and won't clarify the diagnosis.
10. A 79-year-old man with severe peripheral artery disease and a history of a 6.0 cm abdominal aortic aneurysm underwent an endovascular aneurysm repair two weeks ago. He presents to the clinic today with nausea, poor appetite, and worsening blood pressure control. Laboratory studies show a serum creatinine of 2.8 mg/dL (baseline 1.2 mg/dL). Physical examination is notable for a purplish, reticular, lace-like rash on his feet. A complete blood count reveals a peripheral eosinophilia of 8%. Which of the following is the most likely diagnosis?
    Answer: Cholesterol crystal embolization This patient's presentation is classic for cholesterol crystal embolization syndrome (atheroembolism), a complication of angiography or vascular surgery in patients with severe atherosclerosis. Manipulation of the aorta can dislodge cholesterol crystals that embolize to small arteries. The classic triad includes acute or subacute renal failure, livedo reticularis (the described rash), and peripheral eosinophilia. The timing of onset, typically weeks after the inciting procedure, helps distinguish it from contrast-induced nephropathy, which occurs within days.
11. A 28-year-old man presents for a pre-employment physical. He has a blood pressure of 160/90 mmHg in his right arm. He mentions occasional headaches and notes that his legs feel fatigued more quickly than his arms during exercise. Physical examination reveals bounding radial pulses and markedly diminished and delayed femoral pulses. Which of the following findings is most likely to be present on this patient's chest radiograph?
    Answer: Notching of the inferior border of the ribs The patient's presentation, including upper extremity hypertension, diminished lower extremity pulses (brachial-femoral delay), and symptoms of leg claudication, is classic for coarctation of the aorta. In this condition, chronic aortic obstruction leads to the development of collateral circulation through the intercostal and internal mammary arteries to bypass the stenosis. The enlarged, pulsatile intercostal arteries cause pressure erosion on the inferior surfaces of the ribs, leading to the characteristic finding of rib notching on chest radiography.
12. A 67-year-old man comes to your office for a routine follow-up. He reports that he ran out of his blood pressure medications, amlodipine and lisinopril, one week ago. He feels well and denies any headache, chest pain, shortness of breath, or visual changes. His blood pressure is 195/110 mmHg. The remainder of his physical examination, including a funduscopic exam, is unremarkable. Which of the following is the most appropriate next step in management?
    Answer: Reinstate his home oral medications and arrange a follow-up visit in 2-3 days This patient has severe asymptomatic hypertension, also known as hypertensive urgency. There is no evidence of acute end-organ damage. The most appropriate management is to reinstate his usual oral antihypertensive medications and ensure close follow-up in a few days to assess the response. Aggressive, acute lowering of blood pressure with parenteral agents or potent oral agents like clonidine in the office is not necessary and can be harmful, potentially causing hypoperfusion. Admission to the hospital or referral to the emergency department is not indicated for asymptomatic severe hypertension.
13. A 42-year-old woman is undergoing an elective laparoscopic cholecystectomy. Shortly after the induction of anesthesia, her blood pressure rises to 220/130 mmHg and her heart rate to 140/min. The procedure is aborted. After she is stabilized, she mentions having had episodic headaches, sweating, and palpitations for the past year. Which of the following is the most appropriate initial step in her diagnostic workup?
    Answer: Measurement of plasma free metanephrines The patient's history of paroxysmal symptoms (headache, sweating, palpitations) combined with a severe hypertensive crisis triggered by anesthesia is highly suggestive of a pheochromocytoma. The initial step in diagnosis is biochemical confirmation of catecholamine excess. Measurement of plasma free metanephrines or 24-hour urinary fractionated metanephrines and catecholamines are the screening tests with the highest sensitivity. Anatomic imaging with CT or MRI should only be performed after biochemical evidence confirms the diagnosis, in order to locate the tumor.
14. A 29-year-old woman of East Asian descent presents with a 3-month history of fatigue, low-grade fevers, and arthralgias. She also reports pain and weakness in both arms when she blow-dries her hair or carries groceries. On examination, her blood pressure is 160/95 mmHg in the right arm but unobtainable by cuff in the left arm. Bruits are audible over both subclavian arteries. Her erythrocyte sedimentation rate is 95 mm/hr. Which of the following is the most likely diagnosis?
    Answer: Takayasu arteritis This patient's presentation is classic for Takayasu arteritis, a large-vessel vasculitis that primarily affects the aorta and its major branches. It typically occurs in women younger than 50, often of Asian descent. The clinical picture includes systemic constitutional symptoms (fever, fatigue), evidence of vascular inflammation (elevated ESR), and signs of vessel stenosis such as blood pressure discrepancies between limbs, arterial bruits, and limb claudication. Giant cell arteritis affects patients >50. FMD does not cause systemic inflammation. Polyarteritis nodosa is a medium-vessel vasculitis that typically spares the aorta.
15. A 78-year-old woman with a known history of atrial fibrillation for which she takes no anticoagulation is brought to the emergency department for a 3-hour history of sudden, severe pain in her right leg. On examination, the leg is cool and pale from the mid-shin down. She has profound weakness of dorsiflexion and plantar flexion of the foot, and sensation is diminished to light touch. Popliteal, dorsalis pedis, and posterior tibial pulses are absent on the right. After initiating an intravenous heparin infusion, which of the following is the most critical and time-sensitive next step in management?
    Answer: Obtain an emergent vascular surgery consultation This patient has acute limb ischemia, likely from an arterial embolism from her untreated atrial fibrillation. This is a vascular emergency. The presence of motor and sensory deficits indicates a threatened limb (Rutherford class IIb), which requires immediate intervention to prevent irreversible tissue damage and amputation. After starting systemic anticoagulation with heparin, the most critical next step is an emergent consultation with vascular surgery for revascularization, which may involve catheter-directed thrombolysis or surgical embolectomy. Delaying this consultation for imaging could compromise limb viability. Time is tissue.
16. A 65-year-old man is on postoperative day 1 following an elective right hemicolectomy. His past medical history is significant for hypertension, for which he takes oral amlodipine at home. He is currently receiving patient-controlled analgesia and is NPO. His nurse reports a blood pressure of 185/100 mmHg. The patient rates his pain as 3/10. He is afebrile with a heart rate of 95/min. In addition to ensuring adequate analgesia, which of the following is the most appropriate next step to manage his blood pressure?
    Answer: Administer intravenous labetalol This patient has acute postoperative hypertension and is NPO, requiring parenteral medication. Intravenous labetalol is an excellent choice as it is a mixed alpha- and beta-blocker that lowers blood pressure without causing significant reflex tachycardia. Intravenous hydralazine is a direct vasodilator that can cause reflex tachycardia and is less predictable, making it a second-line option. Nitroglycerin is primarily a venodilator and is not a first-line agent for hypertension without active myocardial ischemia. Crushing oral medications is often not appropriate in the immediate postoperative period when gut motility is uncertain and the patient is NPO.
17. A 55-year-old man with a history of poorly controlled hypertension presents to the emergency department with a sudden onset of severe, tearing chest pain that radiates to his back. His blood pressure is 190/110 mmHg, and his heart rate is 115/min. Aortic dissection is suspected, and a CT angiogram is ordered. While awaiting the scan, which of the following is the most appropriate immediate intervention?
    Answer: Intravenous esmolol In a patient with suspected acute aortic dissection, the immediate goals are to reduce aortic shear stress by controlling both heart rate and blood pressure. The rate of rise of the aortic pressure (dP/dt) is a major determinant of aortic wall stress, and this is directly related to heart rate. Therefore, heart rate control must be established before blood pressure control. Intravenous beta-blockers, such as esmolol or labetalol, are the first-line agents. Vasodilators like hydralazine or nitroglycerin should not be used alone as they can cause reflex tachycardia, which would increase shear stress and potentially worsen the dissection.
18. A 55-year-old man with hypertension and a history of recurrent gouty arthritis presents for medication management. His blood pressure is 155/92 mmHg despite adherence to amlodipine 10 mg daily. He has had two gout flares in the past year while taking allopurinol. Laboratory studies show a serum uric acid of 8.9 mg/dL. Which of the following medications would be the most appropriate addition to his antihypertensive regimen?
    Answer: Losartan This question requires selecting an antihypertensive agent based on its effect on a comorbid condition. Among the angiotensin II receptor blockers (ARBs), losartan has a unique uricosuric effect, meaning it increases the urinary excretion of uric acid and can lower serum uric acid levels. This makes it a particularly good choice for patients with both hypertension and gout. In contrast, thiazide diuretics like hydrochlorothiazide are known to increase serum uric acid and can precipitate gout flares. While ACE inhibitors and beta-blockers are options for hypertension, they do not offer the specific benefit for hyperuricemia that losartan does.
19. A 60-year-old man with Marfan syndrome is found on a screening echocardiogram to have a 4.8-cm ascending thoracic aortic aneurysm. His blood pressure is 135/85 mmHg. He is asymptomatic. Which of the following medications is most appropriate to initiate for the long-term medical management of his aortic aneurysm?
    Answer: Metoprolol Medical therapy to slow the rate of expansion of thoracic aortic aneurysms, particularly in patients with connective tissue disorders like Marfan syndrome, is crucial. The primary goal is to reduce aortic wall shear stress. Beta-blockers, such as metoprolol or atenolol, are considered first-line therapy as they decrease the rate of pressure change in the aorta (dP/dt) by reducing heart rate and contractility. Angiotensin II receptor blockers (ARBs) are also used, often in combination with beta-blockers. ACE inhibitors and calcium channel blockers have not been shown to be as effective in this specific context. Aspirin has no role in slowing aneurysm growth.
20. An 80-year-old woman with long-standing hypertension, coronary artery disease, and peripheral artery disease is started on ramipril. One week later, she complains of new-onset nausea and fatigue. Her blood pressure is 140/80 mmHg. Laboratory studies are significant for a serum creatinine that has increased from a baseline of 1.3 mg/dL to 2.9 mg/dL. This patient's acute kidney injury is most likely due to the new medication's effect on which of the following physiologic mechanisms?
    Answer: Efferent arteriolar vasodilation This patient with extensive atherosclerotic disease likely has underlying bilateral renal artery stenosis. In this condition, glomerular filtration rate (GFR) is maintained by angiotensin II-mediated vasoconstriction of the efferent arteriole. Initiating an ACE inhibitor (ramipril) blocks the production of angiotensin II, leading to vasodilation of the efferent arteriole. This causes a precipitous drop in intraglomerular pressure and a subsequent sharp decline in GFR, manifesting as acute kidney injury. Afferent arteriolar vasoconstriction is a mechanism of NSAID-induced AKI.

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