A 38-year-old woman presents with 8 months of progressive exertional dyspnea (NYHA III), exertional chest tightness, and one syncopal episode while climbing stairs. Examination reveals a left parasternal heave, loud P2, and a holosystolic murmur at the lower left sternal edge increasing with inspiration. Her ECG is shown in the diagram marked **A**, demonstrating sinus rhythm with marked right axis deviation (+120°), tall R wave in V1 (7 mm) with R/S 1, deep S in V6, T-wave inversion in V1–V3, and P pulmonale. Which of the following investigations is the SCREENING TEST OF CHOICE to evaluate the structural and hemodynamic consequences of the ECG abnormality shown in **A**?

Question

A 38-year-old woman presents with 8 months of progressive exertional dyspnea (NYHA III), exertional chest tightness, and one syncopal episode while climbing stairs. Examination reveals a left parasternal heave, loud P2, and a holosystolic murmur at the lower left sternal edge increasing with inspiration. Her ECG is shown in the diagram marked **A**, demonstrating sinus rhythm with marked right axis deviation (+120°), tall R wave in V1 (>7 mm) with R/S > 1, deep S in V6, T-wave inversion in V1–V3, and P pulmonale. Which of the following investigations is the SCREENING TEST OF CHOICE to evaluate the structural and hemodynamic consequences of the ECG abnormality shown in **A**?

Accepted Answer

A. Transthoracic echocardiography with Doppler assessment of tricuspid regurgitation jet velocity. ## Why Transthoracic echocardiography is right

The ECG pattern marked **A** — right axis deviation, tall R in V1 with R/S > 1, deep S in V6, T-wave inversion in V1–V3, and P pulmonale — is diagnostic of right ventricular hypertrophy (RVH) secondary to pulmonary hypertension. According to the ESC/ERS PH Guidelines 2022, **transthoracic echocardiography is the screening test of choice** for suspected pulmonary hypertension. It non-invasively estimates systolic pulmonary artery pressure (PASP) via the tricuspid regurgitation jet, assesses RV size and function, detects septal flattening with D-shaped LV (pressure overload pattern), and guides the decision for right heart catheterization. In this patient, echo would show estimated PASP 75 mmHg, RV dilatation and hypokinesis, and normal LV systolic function — all consistent with pre-capillary PH.

## Why each distractor is wrong

- **Right heart catheterization**: While definitive for PH diagnosis and classification (confirming mPAP ≥20 mmHg, PCWP ≤15 mmHg, PVR >2 Wood units), it is an invasive procedure reserved for confirmation and risk stratification *after* echocardiographic screening, not the initial screening test.
- **High-resolution CT chest with pulmonary angiography**: HRCT is part of the diagnostic workup to assess for underlying lung disease (Group 3 PH) or structural abnormalities, but it is not the screening test of choice for hemodynamic assessment of RVH.
- **Ventilation-perfusion scan**: V/Q scan is performed to exclude chronic thromboembolic pulmonary hypertension (CTEPH, Group 4), which is surgically curable by pulmonary endarterectomy. It is a targeted investigation in the etiologic workup, not the initial screening test.

**High-Yield:** Echocardiography is the first-line screening tool for suspected PH; RHC is the gold standard for diagnosis and classification; V/Q scan excludes surgically curable CTEPH.

[cite: ESC/ERS PH Guidelines 2022]

Answer

B. Right heart catheterization with measurement of mean pulmonary artery pressure and pulmonary vascular resistance

Answer

C. Ventilation-perfusion scan to assess for chronic thromboembolic disease

Answer

D. High-resolution CT chest with pulmonary angiography protocol

Explanation

Why Transthoracic echocardiography is right

Why each distractor is wrong

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