Physicians frequently underestimate or overestimate disease progression risk in patients with World Health Organization (WHO) functional class (FC) II pulmonary arterial hypertension (PAH), at least compared with objective risk assessment methods, a study published in PLoS One suggests.

In a retrospective chart analysis, a team of researchers based in the United States surveyed 38 pulmonologists or cardiologists with at least 3 years of post-training experience treating 3 or more patients with PAH and FC II symptoms.

A total of 153 patient charts were obtained from the physicians for review. Only patients with PAH treated with monotherapy or dual therapy in the preceding 12 months were included. Physicians were asked to provide an assessment of patient risk using clinical judgment. An independent reviewer subsequently calculated patient risk using the COMPERA method, a modified noninvasive version of the French Pulmonary Hypertension Registry (FPHR) method, and the REVEAL 2.0 tool. The investigators then examined factors associated with incongruent risk assessment.

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Surveyed physicians said they saw a median of 60 patients with PAH per year (range, 8-1200), approximately 45% of whom had WHO FC II PAH. Physician assessment classified 41% of patients as low risk, 46% of patients as intermediate risk, and 13% of patients as high risk. The concordance between physician gestalt and objective methods ranged between 43% and 54%.

Objective methods attributed high risk status to between 4% and 28% of patients who were considered low risk by physician gestalt. Less frequent echocardiography during follow up was identified as the most common physician-related factor associated with incongruent risk assessment (every 7-12 months vs every 3 months; P =.01).

Limitations of this study included its retrospective nature, the lack of long-term outcomes data, as well as the small sample size of physicians and patient charts.

“The utilization of risk assessment tools could uncover intermediate- and high-risk patients with underestimated risk and complement physician gestalt to better inform treatment decisions,” the researchers concluded. “The observed variance between different risk assessment tools…underscores the need for prospective evaluation of risk assessment tools in the real-world setting.”

Disclosure: This clinical trial was supported by Actelion Pharmaceuticals. Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Sahay S, Tonelli AR, Selej M, Watson Z, Benza RL. Risk assessment in patients with functional class II pulmonary arterial hypertension: comparison of physician gestalt with ESC/ERS and the REVEAL 2.0 risk score. PLoS One. Published online November 11, 2020. doi: 10.1371/journal.pone.0241504