A 75-year-old white woman was evaluated for chronic cough and dyspnea on exertion. She was previously treated (at age 50 years) for pleurisy and chronic, unresolved pneumonia. Her sister was being treated elsewhere for severe chronic obstructive pulmonary disease (COPD). The patient's spirometry measurements were: forced vital capacity (FVC), 1.9 L; forced expiratory volume in 1 second (FEV₁), 1.1 L; FEV₁ as a percentage of FVC, 57%; maximum ventilatory volume, 48 L/min. These measurements did not improve after bronchodilator therapy. She never smoked. The patient's electrocardiogram showed complete right bundle-branch block, and a 2-dimensional echocardiogram revealed severe tricuspid regurgitation. The right ventricular systolic pressure was estimated at 54 mm Hg. Her chest radiograph is shown (Figure).

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