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Non-ST-elevation acute coronary syndrome — MCCQE Part 1 MCQ

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HardChest PainNon-ST-elevation acute coronary syndromeMCCQE Part 1

A 44-year-old woman with systemic sclerosis has progressive exertional dyspnoea, reduced diffusing capacity, elevated NT-proBNP, and echocardiographic findings strongly suggestive of pulmonary hypertension. CT excludes major parenchymal lung disease and ventilation-perfusion scanning is normal. Which investigation is required before starting pulmonary arterial hypertension therapy?

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Correct answer: D — Right-heart catheterisation at an experienced centre

Echocardiography estimates the probability of pulmonary hypertension but cannot reliably measure pulmonary arterial wedge pressure, cardiac output, or pulmonary vascular resistance. Right-heart catheterisation is therefore required in an experienced centre to confirm pulmonary hypertension, distinguish pre-capillary PAH from left-heart or mixed disease, quantify severity, and guide treatment. This distinction is especially important in systemic sclerosis, where myocardial, interstitial-lung, and pulmonary vascular disease can coexist. Empiric PAH therapy before haemodynamic classification can be ineffective or harmful. Repeating echocardiography delays a high-risk diagnosis, while coronary calcium scoring and lung biopsy do not provide the required haemodynamics.

Reference: ESC/ERS Pulmonary Hypertension Guideline: https://publications.ersnet.org/content/erj/61/1/2200879