A previously healthy 61-year-old man comes to the physician because of a 6-month history of morning headaches. He also has fatigue and trouble concentrating on his daily tasks at work. He sleeps for 8 hours every night; his wife reports that he sometimes stops breathing for a few seconds while sleeping. His pulse is 71/min and blood pressure is 158/96 mm Hg. He is 178 cm (5 ft 10 in) tall and weighs 100 kg (220 lb); BMI is 31.6 kg/m2 . Which of the following is the most likely cause of this patient's hypertension?

Nocturnal upper airway obstruction

Proliferation of adrenal chromaffin cells

A 56-year-old woman comes to the physician for follow-up after a measurement of elevated blood pressure at her last visit three months ago. She works as a high school teacher at a local school. She says that she mostly eats cafeteria food and take-out. She denies any regular physical activity. She does not smoke or use any recreational drugs. She drinks 2 to 3 glasses of wine per day. She has hypercholesterolemia for which she takes atorvastatin. Her height is 165 cm (5 ft 5 in), weight is 82 kg (181 lb), and BMI is 30.1 kg/m2. Her pulse is 67/min, respirations are 18/min, and blood pressure is 152/87 mm Hg on the right arm and 155/92 mm Hg on the left arm. She would like to try lifestyle modifications to improve her blood pressure before considering pharmacologic therapy. Which of the following lifestyle modifications is most likely to result in the greatest reduction of this patient's systolic blood pressure?

Losing 15 kg (33 lb) of body weight

Walking for 30 minutes, 5 days per week

Reducing sodium intake to less than 2.4 g per day

Decreasing alcohol consumption to maximum of one drink per day

A 68-year-old woman comes to the physician for a follow-up visit for elevated blood pressure. Two weeks ago, her blood pressure was 154/78 mm Hg at a routine visit. Subsequent home blood pressure measurements at days 5, 10, and 14 have been: 156/76 mm Hg, 158/80 mm Hg, and 160/80 mm Hg. She has trouble falling asleep but otherwise feels well. She had a cold that resolved with over-the-counter medication 2 weeks ago. She has a history of primary hypothyroidism and a cyst in the right kidney, which was found incidentally 20 years ago. She takes levothyroxine. She is 178 cm (5 ft 10 in) tall and weighs 67 kg (148 lb); BMI is 21.3 kg/m2. Her pulse is 82/min, and blood pressure is 162/79 mm Hg. Examination shows no abnormalities. Laboratory studies, including thyroid function studies, serum electrolytes, and serum creatinine, are within normal limits. Which of the following is the most likely underlying cause of this patient's blood pressure findings?

Decrease in arterial compliance

Medication-induced vasoconstriction

Decrease in baroreceptor sensitivity

Increase in aldosterone production

A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?

Perforation of the esophageal wall

Obstruction of the pulmonary arteries

Fibrofatty plaque in the aortic wall

A 59-year-old man presents to the emergency department with a sudden onset of severe pain (10/10 in severity) between the shoulder blades. He describes the pain as tearing in nature. Medical history is positive for essential hypertension for 11 years. The patient has smoked 10–15 cigarettes daily for the past 30 years. His temperature is 36.6°C (97.8°F), the heart rate is 107/min, and the blood pressure is 179/86 mm Hg in the right arm and 157/72 mm Hg in the left arm. CT scan of the chest shows an intimal flap limited to the descending thoracic aorta. Which of the following best describes the most likely predisposing factor for this condition?

Abnormal elastic properties of the aorta

Preventive cardiology for USMLE Step 1: High-Yield Internal Medicine Lessons

Lipid Management - Grease Police

Statins (HMG-CoA Reductase Inhibitors): First-line therapy to ↓ LDL.
- High-Intensity: Atorvastatin 40-80mg, Rosuvastatin 20-40mg (↓LDL >50%).
- Moderate-Intensity: Atorvastatin 10-20mg, Simvastatin 20-40mg (↓LDL 30-50%).
- Monitor LFTs, CK at baseline.
Ezetimibe: Inhibits intestinal cholesterol absorption. Good add-on to statins.
PCSK9 Inhibitors (e.g., Alirocumab): Powerful LDL lowering; used for refractory cases or familial hypercholesterolemia (FH).

⭐ Beyond lipid lowering, statins stabilize atherosclerotic plaques, reducing rupture risk.

Mechanisms of action: Statins, Ezetimibe, PCSK9 inhibitors

Hypertension - Pressure Cooker

Definition: Sustained blood pressure >130/80 mmHg on ≥2 readings.
Types:
- Primary (Essential): ~95% of cases; idiopathic, strong genetic/lifestyle links.
- Secondary: Suspect in young (<30) or resistant HTN.
  - 📌 ROPE: Renal (RAS, CKD), OSA, Pheochromocytoma/Primary aldosteronism, Endocrine (Cushing's, thyroid).
Complications (End-Organ Damage):
- Heart: LVH, CHF, CAD
- Brain: CVA, dementia
- Kidney: Hypertensive nephrosclerosis → CKD
- Eyes: Retinopathy

Hypertension and Organ Damage

⭐ Isolated systolic hypertension (ISH), SBP ≥130 mmHg with DBP <80 mmHg, is common in older adults and a major cardiovascular risk factor.

Lifestyle & Other RFs - Habit Heroes

Diet: DASH or Mediterranean style.
- ↓Na⁺ (<2.3 g/day), ↑K⁺, fruits, vegetables, whole grains, lean protein.
Exercise: Aerobic activity.
- 150 min/week moderate intensity (e.g., brisk walk) OR
- 75 min/week vigorous intensity (e.g., running).
Weight: Target BMI <25 kg/m². Initial goal: ↓5-10% body weight.
Alcohol: Moderation.
- Men: ≤2 drinks/day; Women: ≤1 drink/day.
Smoking: Cessation is critical. Counseling (5 A's) & pharmacotherapy.

⭐ Smoking cessation halves MI risk within 1 year.

DASH Diet food groups and serving recommendations

Risk Stratification - Future Forecasters

ASCVD Pooled Cohort Equations (PCE): Estimates 10-year risk of first hard atherosclerotic cardiovascular event.
- Inputs: Age, sex, race, cholesterol (total, HDL), SBP, BP meds, DM, smoking.
Coronary Artery Calcium (CAC) Score: A key decision aid for intermediate-risk patients.
- CAC = 0: Favors avoiding statins.
- CAC = 1-99: Favors statin therapy.
- CAC ≥ 100 or ≥75th percentile: Initiate statin therapy.

⭐ A CAC score of 0 ("Power of Zero") is a powerful de-risking tool. In patients with borderline/intermediate ASCVD risk, it lowers 10-year event risk to <1%, allowing for safe deferral of statin therapy.

Coronary Artery Calcification: Diagram & CT Scan

High‑Yield Points - ⚡ Biggest Takeaways

Aspirin for primary prevention is now risk-based, not routine, due to bleeding risk.

Statins are central; know the four major statin benefit groups for ASCVD risk reduction.

Target blood pressure is generally <130/80 mmHg; lifestyle changes are foundational.

The Mediterranean diet is the most evidence-based dietary pattern for CV risk reduction.

Advise 150 min/week of moderate-intensity aerobic exercise.

ASCVD risk calculation should be periodically performed for all adults >20 years.

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