Pulmonary arterial hypertension (PAH) is a progressive, life-threatening disease where early detection is strongly encouraged to prevent irreversible vascular and cardiac damage. However, a fundamental paradox exists: while clinicians are urged to diagnose pulmonary arterial hypertension early, treatment is restricted to symptomatic patients (New York Heart Association (NYHA) functional class II or higher), leaving asymptomatic class I patients untreated despite ongoing disease progression.
This “diagnose early, treat late” approach contradicts evidence from other chronic diseases—including cancer, HIV, hepatitis, and cardiovascular conditions—where early intervention before symptom onset has proven beneficial. The current pulmonary arterial hypertension paradigm inadvertently enforces a “wait and see” strategy that exposes asymptomatic patients to preventable deterioration.
The authors call for reassessment of clinical guidelines, regulatory frameworks, and treatment access policies to align with pulmonary arterial hypertension biological realities. They advocate for including New York Heart Association (NYHA) functional class I patients in treatment strategies while acknowledging current evidence limitations and emphasizing the need for rigorous research addressing counterarguments and practical challenges of early intervention.
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Citation
Orozco-Levi M, de Jesús Pérez VA, Pulido T, Pabón-Quezada A, Morisky P, Conde-Camacho R, Ramírez-Sarmiento A. Why Wait for Sick People to Get Sicker? The Paradox of the Treatment of Patients With Pulmonary Arterial Hypertension. Pulm Circ. 2025 Nov 20;15(4):e70202. doi: 10.1002/pul2.70202. PMID: 41281580; PMCID: PMC12635416.