List 4 clinical signs on cardiovascular examination which will support the diagnosis of pulmonary hypertension

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College Answer

°     Prominent ‘a’ wave

°     Parasternal lift

°     Palpable P2

°     Loud P2

°     Features of tricuspid regurgitation

Discussion

The signs of pulmonary hypertension are mainly indirect.

  • The split loud P2 is the only direct sign - it is the sound of elevated PA pressur slamming the pulmonic valve shut at the end of systole.
  • If the P2 is palpable, the PA pressure is truly uncontrollably high

The rest are all features of right heart failure.

  • Parasternal heave is a sign of RV hypertrophy
  • a prominent "a" wave is the wave of right atrial contraction, reflected from either a stenotic tricuspid valve or a stiff non-compliant right ventricle. This also suggests that the RV is hypertrophied.
  • Features of tricuspid regurgitation suggest that the RV is also dilated, and possibly decompensating.

References

References

UpToDate: Clinical features and diagnosis of pulmonary hypertension in adults

SLEEPER, JULIAN C., EDWARD S. ORGAIN, and HENRY D. MCINTOSH. "Primary Pulmonary Hypertension Review of Clinical Features and Pathologic Physiology with a Report of Pulmonary Hemodynamics Derived from Repeated Catheterization." Circulation 26.6 (1962): 1358-1369.

(this is a nice old-school article witrh a discussion of several cases of severe pulmonary hypertension, and its various clinical features)