Which findings would you expect in pulmonary hypertension on physical examination and imaging?

• A. Decreased P2
• B. Normal P2
• C. Loud P2 only
• D. Increased pulmonary vascular markings with a loud P2

Answer: (D)

Pulmonary hypertension elevates pressures in the pulmonary arteries, so the pulmonic component of the heart sounds becomes louder as the pulmonary valve closes against high pressure. This results in a distinctly loud P2 on exam. On imaging, the increased pressure and blood flow commonly produce enlargement of the central pulmonary arteries and more prominent vascular markings due to vascular congestion. Putting these together, the combination of a loud P2 and increased pulmonary vascular markings best fits pulmonary hypertension. Decreased or normal P2 would not fit the expected auscultatory change, and a loud P2 alone would miss the imaging finding of vascular enlargement.