Primary Risk Factor: Hypertension and Obesity (Combined)
The primary risk factor for this patient's exertional symptoms is the combination of hypertension and obesity (BMI 31), not his age, past smoking history, or mild left ventricular hypertrophy alone. 1, 2
Why HTN and Obesity Are the Culprits
The American Heart Association identifies hypertension as the leading modifiable cardiovascular disease risk factor, and when combined with obesity, these conditions create a synergistic effect that exceeds the sum of individual risk factors 1, 2. In this patient's case:
- Hypertension directly impairs exercise tolerance through accelerated atherosclerosis, vascular remodeling, and impaired peripheral circulation 1
- Among adults with hypertension, 49.5% are obese, resulting in high absolute risks for cardiovascular events, with 41.7% having a 10-year coronary heart disease risk >20% 1
- Obesity creates a synergistic effect with hypertension, with 35.7% of obese individuals having hypertension 1, 3
- The combination drives left ventricular hypertrophy and contributes to heart failure with preserved ejection fraction, which manifests as exertional dyspnea 3
Why Other Options Are Incorrect
Option A (Smoking) - WRONG
- Smoking cessation occurred 15 years ago, placing him well beyond the period of elevated acute risk 4
- While smoking is a well-documented modifiable risk factor for stroke and cardiovascular disease 4, its contribution to current symptoms is minimal compared to active hypertension and obesity
Option C (Normal for Age) - WRONG
- Exercise intolerance requiring medical evaluation is never "normal for age" and represents pathology requiring intervention 1, 2
- The American College of Cardiology explicitly states that difficulty with activities of daily living represents disease, not aging 1, 2
Option D (Mild LVH Alone) - WRONG
- LVH is a consequence, not a primary cause - it results from the chronic effects of hypertension and obesity 4, 3, 5
- The chief determinants of LVH are elevated blood pressure, obesity, stature, and glucose intolerance 5
- While LVH independently increases cardiovascular risk 6-8 fold 6, it is the downstream manifestation of poorly controlled hypertension and obesity 4, 7
Clinical Implications
Blood pressure control is imperative with target <140/90 mmHg, as this directly addresses the mechanism limiting exercise tolerance 2, 3. Hypertension treatment reduces heart failure risk by approximately 50% 3.
Weight loss combined with structured exercise programs increases pain-free and maximum walking distances despite initial discomfort 1, 3.
In obese hypertensive patients with ischemic heart disease, blood pressure control is achieved in only 34.69% compared to 51.52% in normal-weight patients, highlighting the compounded difficulty of management 8.
Answer: B (HTN and obesity)