Treatment differences in pulmonary arterial hypertension management

Editor:

We read with interest the survey-based study by Preston and colleagues¹ reporting on physician adherence to clinical guidelines for the diagnosis of pulmonary arterial hypertension (PAH) and international trends in the treatment of patients. Their findings illustrate underutilization of right heart catheterization for diagnosing PAH and demonstrate important regional differences in implementation of PAH-specific therapy.

We note the opening statement of the “Discussion” section, which suggests that these findings are from the first physician-based perception study characterizing similarities and differences in the diagnosis and management of PAH globally. In our view, this omits important contributions on the topic published elsewhere.^2-4 For example, we reported findings from a survey completed by 105 expert PAH clinicians practicing in 25 different countries.⁵ In that study, wide variability in PAH drug preference and deviation from expert consensus guidelines for PAH diagnosis were observed across the entire study cohort and, specifically, between US and non-US respondents. Findings from Preston and colleagues and our report are consistent in demonstrating persistent misconceptions among practitioners regarding requirements for diagnosing and treating PAH, which has also been reported widely using alternative research methods.^6,7 Despite this sizeable literature, the precise factors that contribute to treatment differences and practice guideline nonadherence remain incompletely characterized. Indeed, addressing this unanswered question would seem necessary for determining the extent to which practice variability is a modifiable contributor to adverse outcome in PAH.