Primary Risk Factor: Hypertension and Obesity
The primary risk factor for this patient's difficulty walking short distances is the combination of hypertension and obesity (BMI 31), not smoking cessation from 15 years ago or normal aging. 1, 2
Why HTN and Obesity Are the Culprit
The patient's presentation strongly suggests peripheral arterial disease (PAD) or early cardiovascular compromise driven by active, modifiable risk factors:
Obesity (BMI 31) creates a synergistic effect with hypertension that exceeds the sum of individual risk factors, with 35.7% of obese individuals having hypertension 3, 1
Hypertension accelerates atherosclerosis and vascular remodeling, directly impairing peripheral circulation and exercise tolerance 1, 4
The combination drives multiple pathophysiological mechanisms: neurohormonal activation, inflammation, endothelial dysfunction, and kidney dysfunction that perpetuate cardiovascular disease 5, 6
Among US adults with hypertension, 49.5% are obese, and this clustering results in high absolute risks for cardiovascular events—41.7% have a 10-year CHD risk >20% 3
Why Smoking Is NOT the Primary Factor
Smoking cessation 15 years ago means the acute thrombotic and vasospastic effects have long resolved 4
While former smoking contributes to atherosclerotic burden, the active, ongoing metabolic assault from obesity-hypertension is the dominant driver of current symptoms 1
The American Heart Association identifies hypertension as the leading modifiable CVD risk factor, second only to current cigarette smoking as a preventable cause of death 3
Why "Normal for Age" Is Wrong
Exercise intolerance requiring medical evaluation is never "normal for age" and represents pathology requiring intervention 2
The American College of Cardiology explicitly states that difficulty with activities of daily living represents disease, not aging 2
Clinical Implications
This patient likely has PAD or early heart failure with preserved ejection fraction (HFpEF):
Ankle-brachial index (ABI) testing should be performed immediately, as values <0.90 are 95% sensitive and specific for PAD 1
Obesity is present in >70% of adult HFpEF patients, and the combination with hypertension drives left ventricular hypertrophy and exertional dyspnea 2
Blood pressure control reduces MI, stroke, heart failure, and death risk in PAD patients, with target <140/90 mmHg 3, 1
Weight loss combined with structured exercise programs increases pain-free and maximum walking distances despite initial discomfort 1, 2
Answer: B (Hypertension and Obesity)