What is the next test to order for a 55-year-old patient with severe fatigue, bilateral ankle edema, mild obesity, and an enlarged cardiac silhouette, with EKG (electrocardiogram) showing right axis deviation and echocardiogram showing right ventricular dilation and elevated right ventricular systolic pressure?

From the Guidelines

The next test to order for this patient is a ventilation-perfusion (V/Q) scan to evaluate for pulmonary hypertension, specifically to rule out chronic thromboembolic pulmonary hypertension (CTEPH). Given the patient's presentation with severe fatigue, bilateral ankle edema, and cardiac findings consistent with right heart strain (right axis deviation on EKG, right ventricular dilation and elevated right ventricular systolic pressure on echocardiogram), there is strong evidence of pulmonary hypertension 1. The V/Q scan is particularly sensitive for detecting CTEPH, which is a potentially treatable cause of pulmonary hypertension resulting from organized thrombi in the pulmonary arteries. According to the 2015 ESC/ERS guidelines, a V/Q scan is recommended to rule out CTEPH in patients with suspected pulmonary hypertension 1.

Some key points to consider in the diagnostic approach include:

• The patient's symptoms and echocardiogram findings are consistent with pulmonary hypertension, which requires further evaluation to determine the underlying cause.
• A V/Q scan is a sensitive test for detecting CTEPH, and if positive, would prompt further evaluation with right heart catheterization to confirm the diagnosis and measure pulmonary artery pressures directly.
• The diagnostic approach should be guided by the most recent and highest quality evidence, which in this case supports the use of V/Q scan as the next step in evaluation 1.
• Other tests, such as CT pulmonary angiogram (CTPA), may also be considered, but the V/Q scan is the recommended initial test for evaluating CTEPH 1.

In terms of the patient's management, it is crucial to identify the specific etiology of pulmonary hypertension to guide appropriate treatment, which may include anticoagulation, pulmonary vasodilators, or in some cases, surgical intervention such as pulmonary thromboendarterectomy for CTEPH 1. The patient's symptoms and echocardiogram findings suggest a high probability of pulmonary hypertension, and further evaluation with a V/Q scan is necessary to determine the underlying cause and guide treatment.

From the Research

Diagnostic Approach

The patient's symptoms and test results suggest the possibility of pulmonary hypertension. Given the EKG showing right axis deviation and echocardiogram showing right ventricular dilation and elevated right ventricular systolic pressure, the next step in diagnosis should focus on confirming the presence and severity of pulmonary hypertension.

Test Options

• Right Heart Catheterization: This is considered the gold standard for diagnosing pulmonary hypertension and assessing the severity of the disease 2, 3, 4. It provides direct measurements of pulmonary artery pressure and can help guide treatment decisions.
• Exercise Stress Test: While useful for assessing exercise tolerance and detecting signs of pulmonary hypertension during exertion, it is not the primary diagnostic tool for pulmonary hypertension 5.
• Polysomnography: This test is used to diagnose sleep disorders and is not directly relevant to the diagnosis of pulmonary hypertension.
• Ventilation-Perfusion Scan: This test can be used to evaluate for pulmonary embolism or other lung diseases but is not the primary diagnostic tool for pulmonary hypertension 5.

Recommendation

Based on the provided evidence, the most appropriate next test to order for this patient would be Right Heart Catheterization. This test will provide the necessary information to confirm the diagnosis of pulmonary hypertension, assess its severity, and guide treatment decisions 2, 3, 4. The patient's symptoms and initial test results align with the indications for right heart catheterization as outlined in the studies 2, 3, 6, 5, 4.