Exercise Right Heart Catheterization: The Key to Unraveling the Mystery of Recurrent Syncope.

BACKGROUND

Exercise right heart catheterization (RHC) is a valuable diagnostic tool for identifying hemodynamic abnormalities that may not be evident at rest.

CASE SUMMARY: A 36-year-old woman presented with recurrent exertional syncope and dyspnea. Initial resting studies were inconclusive. Resting RHC revealed mild precapillary pulmonary hypertension (PH). However, exercise RHC unmasked a disproportionate increase in mean pulmonary artery pressure during exertion, diagnostic of exercise-induced pulmonary arterial hypertension (EIPAH). Vasoreactivity testing with inhaled nitric oxide demonstrated favorable pulmonary vascular responsiveness. Autoimmune workup confirmed systemic lupus erythematosus. The patient was started on medical therapy and referred to rheumatology and the PH clinic.

DISCUSSION: This case highlights the role of exercise RHC in detecting early pulmonary vascular disease and supports vasoreactivity testing to guide therapy. EIPAH may be the initial manifestation of autoimmune disease and should be considered in young patients with exertional symptoms and nondiagnostic resting evaluations.

TAKE-HOME MESSAGES: Exercise RHC can reveal latent PH when resting measurements are nondiagnostic. In patients with unexplained exertional symptoms, EIPAH should be considered. EIPAH may be the initial manifestation of an underlying autoimmune condition such as systemic lupus erythematosus.