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A 73-year-old retired miner, with 36 years ‘at the coal face’, presented with a 5-year history of exertional dyspnoea on climbing steep inclines. His medical history was limited to quiescent chronic lymphocytic lymphoma, for which he required no chemotherapy or radiotherapy and had annual haematology follow-up. He was a smoker, with a 15 pack-year history, and took no regular medications.
The patient had a widely split second heart sound, with accentuation of the pulmonary component, and bilateral intercostal bruits. Echocardiography demonstrated normal left sided chambers, moderate mitral and tricuspid regurgitation, and a raised estimated systolic pulmonary artery pressure of 80 mm Hg. Pulmonary function tests showed an obstructive pattern (FEV1 1.91 L (70% predicted), FVC 3.62 L (101%), FEV1/FVC ratio 53%), with a mildly reduced diffusion capacity (transfer coefficient (KCO) 0.86 mmol/min/KPa/L, 70% predicted). On the incremental shuttle walking test, his oxygen saturations dropped from …