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PAD-BP Intensification — ABIM Board MCQ

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ModerateCardiologyPAD-BP IntensificationABIM Board

A 59-year-old man has stable symptomatic lower-extremity atherosclerotic peripheral artery disease and hypertension. He takes lisinopril 40 mg daily and reports good adherence. Blood pressure measured using proper technique at two separate visits averages 138/84 mm Hg. His serum creatinine and potassium levels are normal, and he has no orthostatic symptoms. Which of the following is the most appropriate next step to reduce his cardiovascular risk?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Add another first-line antihypertensive agent and target a blood pressure below 130/80 mm Hg

The correct answer is D. Atherosclerotic PAD is clinical cardiovascular disease and confers high risk for myocardial infarction, stroke, and cardiovascular death. Current US guidance recommends treating hypertension in patients with PAD to a goal below 130/80 mm Hg. This patient's repeatedly measured blood pressure remains above that goal despite adherence to maximally dosed lisinopril, so another first-line agent should be added. ACE inhibitors and ARBs may reduce major adverse cardiovascular events in PAD and should not be stopped without a contraindication. A target below 140/90 mm Hg is less intensive than current recommendations. Beta-blockers are not prohibited in PAD, but they should not replace an ACE inhibitor solely because PAD is present. Concern about limb perfusion does not justify leaving hypertension inadequately treated.

Reference: 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease, Antihypertensive Therapy for PAD, 2024. https://www.heart.org/~/media/PHD-Files-2/Science-News/2/2024/2024-PAD-guideline-slide-set.pdf