Systemic and Pulmonary Hypertension — WACS Viva & Clinical Scenarios (Cardiovascular Medicine)

Exam-style systemic and pulmonary hypertension viva scenarios with examiner probes and model answers for Internal Medicine candidates.

Scenarios covered

• SCENARIO 1: Hypertensive Emergency with Acute Pulmonary Oedema: A 52-year-old male presents to the emergency department with severe breathlessness, orthopnoea, pink frothy sputum, bilateral coarse crackles across both lung bases, and a blood pressure of 225/135 mmHg. Detail the immediate clinical differentiation between hypertensive emergency and urgency, the target hemodynamic thresholds within the first hour, and the selection of guideline-directed intravenous pharmacotherapy.
• SCENARIO 2: Resistant Hypertension and Workup for Primary Aldosteronism: A 38-year-old female presents with persistent office blood pressure of 165/102 mmHg despite documented adherence to full-dose amlodipine, valsartan, and hydrochlorothiazide. Laboratory evaluation reveals a serum potassium of 3.1 mmol/L. Detail the systematic protocol to exclude pseudo-resistance, the diagnostic screening and confirmatory algorithm for primary aldosteronism including drug washout guidelines, and definitive management.
• SCENARIO 3: Hypertensive Emergency in Acute Type A Aortic Dissection: A 46-year-old male with longstanding untreated hypertension presents with acute tearing retrosternal pain radiating to the back, blood pressure of 200/115 mmHg, a heart rate of 102 beats per minute, and asymmetric radial pulses. Outline the required immediate hemodynamic goals, initial intravenous drug sequencing, diagnostic imaging modalities, and urgent definitive management steps.
• SCENARIO 4: Diagnostic Stratification and Therapeutic Pathways in Pulmonary Hypertension: A 34-year-old female presents with progressive exertional dyspnoea, lower extremity oedema, and recurrent presyncope. Echocardiography demonstrates right ventricular hypertrophy, dilation, and a tricuspid regurgitant jet velocity of 3.8 m/s. Outline the stepwise diagnostic protocol to confirm precapillary pulmonary hypertension, the WHO clinical grouping classification, and the pathway for vasoreactivity testing and targeted pharmacotherapy.
• SCENARIO 5: Severe Pre-eclampsia and Acute Hypertensive Crisis in Pregnancy: A 29-year-old primigravida at 34 weeks of gestation presents with a blood pressure of 175/115 mmHg, 3+ proteinuria, persistent epigastric pain, and hyperreflexia. Detail the emergency maternal stabilization, parenteral antihypertensive choices, seizure prophylaxis protocol, and maternal-fetal indications for urgent delivery.