Systemic and pulmonary vascular disease and prevention
Vascular Disease and Hypertension
Core concepts
Vascular disease and hypertension questions cover accurate blood pressure measurement, primary versus secondary hypertension, resistant hypertension, hypertensive emergencies, aortic dissection, peripheral artery disease, abdominal aortic aneurysm, and venous thromboembolism. Secondary causes include primary aldosteronism, renal artery stenosis, obstructive sleep apnea, thyroid disease, pheochromocytoma, and Cushing syndrome. Hypertensive emergency is severe BP with target-organ damage, not the number alone. Aortic dissection requires rapid blood pressure and impulse control and urgent imaging. PAD may be asymptomatic and is assessed with the ankle-brachial index.
Question traps
Do not diagnose resistant hypertension without adherence and proper technique. White-coat and masked hypertension matter. ACE inhibitors and ARBs can worsen renal function in bilateral renal artery stenosis. In dissection, lower heart rate and shear stress before aggressive vasodilation. Do not use thrombolysis for uncomplicated distal DVT routinely.
Worked example / rule of thumb
A patient with sudden tearing chest pain, unequal arm pressures and a widened mediastinum needs urgent assessment for an acute aortic syndrome. Imaging, perfusion, aortic involvement, blood pressure and contraindications guide immediate stabilization and definitive treatment; anti-impulse treatment is not an instruction to give a beta blocker regardless of shock or severe aortic regurgitation. Rule: treat hypertensive emergency by target-organ damage, not by the absolute pressure alone.
Pulmonary Circulatory Disorders
Core concepts
Pulmonary circulatory disorders include pulmonary arterial hypertension, pulmonary hypertension due to left heart disease, lung disease or hypoxia, chronic thromboembolic disease, and miscellaneous causes. Group 1 PAH requires exclusion of other groups and may need vasoreactivity testing. Acute PE risk stratification uses hemodynamic stability, RV dysfunction, troponin, and bleeding risk. CTEPH is a treatable cause of PH and warrants evaluation after PE with persistent symptoms. Right ventricular failure from pressure overload can cause congestion, low output, and syncope.
Question traps
Do not routinely apply a Group 1 PAH regimen to pulmonary hypertension caused by left heart disease; the mechanism, evidence and clinical circumstances differ and pulmonary edema can result. Do not confuse chronic thromboembolic disease with acute PE. A normal D-dimer is useful only in low or intermediate pretest probability. RV strain on echocardiography is not the same as hemodynamic instability. Remember that PE can cause troponin elevation and ECG changes mimicking ischemia.
Worked example / rule of thumb
A patient with PE and hypotension receives systemic thrombolysis unless contraindicated; a stable patient with RV dysfunction and elevated troponin is intermediate-high risk and needs close monitoring. Rule: in PE, hypotension equals high risk and drives reperfusion.
Preventive Cardiology and Cardiovascular Risk Assessment
Core concepts
Preventive cardiology requires estimating ASCVD risk, modifying lifestyle, and choosing evidence-based pharmacotherapy. Statin intensity is matched to risk and LDL reduction. Diabetes, CKD, familial hypercholesterolemia, and inflammatory disease are risk enhancers. Blood pressure control, smoking cessation, physical activity, weight management, and diet are foundational. Aspirin is used for secondary prevention but not routinely for primary prevention. Lipoprotein(a) and coronary artery calcium can refine selected intermediate-risk decisions. Vaccination and screening for social determinants also support prevention.
Question traps
Do not use a primary-prevention risk score to withhold indicated secondary prevention from someone with established ASCVD. Do not use a single risk score in young patients or those with severe family history. Statins are not interchangeable by dose; know high-intensity options. Aspirin bleeding risk matters. Do not ignore adherence and statin intolerance mislabeled as muscle disease.
Worked example / rule of thumb
In selected primary-prevention patients, a zero coronary calcium score can support deferring a statin after shared decision-making, but smoking, diabetes, severe hypercholesterolemia, strong premature family history and the relevant guideline context can change that interpretation. Rule: risk score first, risk enhancers second, shared decision always.