Case

A 65-year-old woman with hypertension and breast cancer presents for an evaluation of dyspnea. Last year, she underwent chemotherapy without mastectomy. At that time, her prechemotherapy transthoracic echocardiogram was normal. Her chemotherapy was complicated by sepsis, hypotension, and a prolonged hospital stay in the intensive care unit, followed by several days in the wards before being discharged home. Since then, she has had progressive dyspnea on exertion. She saw her primary physician last month, who ordered a nuclear myocardial perfusion study that was negative for ischemia and infarction, but revealed evidence of right ventricular (RV) hypertrophy and RV enlargement.

A repeat echocardiogram demonstrates normal left ventricular systolic function and moderate RV enlargement with RV hypertrophy. The RV systolic pressure is 58 mm Hg. On physical examination, her blood pressure is 139/79 mm Hg and her pulse is 90 bpm and regular. She has an oxygen saturation of 94% on room air. Physical examination is otherwise unremarkable.

What would be the next best step in the work-up for this patient?

A.            Ventilation/perfusion scan

B.            Right and left heart catheterization

C.            Pulmonary function test to rule out chronic obstructive pulmonary disease

D.            Nocturnal polysomnography to rule out obstructive sleep apnea

E.            Cardiac magnetic resonance imaging