Physicians’ Risk Assessment in Patients With PAH Often Varies From Objective Measures

In roughly half of cases assessed, physicians underestimated a patients’ risk, according to multiparametric objective risk-assessment tools.

More than half of patients with functional class (FC) II pulmonary arterial hypertension (PAH) have intermediate or high risk of disease progression according to objective assessments, but many are misclassified as low-risk by their physicians.

That is the main finding from a new study published in the journal PLoS One. The data suggest better incorporation of objective measures into clinical practice would improve risk assessment and treatment of these patients.

Corresponding author Sandeep Sahay, MD, of Houston Methodist Hospital, and colleagues explained that while PAH remains incurable, advances in the treatment of the disease mean that it can be managed for many patients with careful monitoring. For patients with intermediate and high risk, early diagnosis and risk assessment can reduce mortality rates; those with a low risk profile have good survival rates.

Broadly speaking, patients with FC II symptoms are considered to be at low risk of disease progression, Sahay and colleagues wrote.

“By definition, these patients have only mild physical activity limitations and experience discomfort (e.g. dyspnea, fatigue, chest pain) with ordinary physical activities,” they wrote.

However, some evidence has suggested that patients characterized as low-risk based on subjective analysis of their symptoms might actually have a higher risk profile according to objective metrics.

The investigators hypothesized that these objective measures might be better at ascertaining patient risk than physician gestalt. They decided to retrospectively study the charts of 153 patients with PAH and FC II symptoms who were receiving monotherapy or dual therapy.

First, the investigators spoke with the patients’ physicians by phone to understand their methodology, which the authors said sometimes included objective risk assessment.

Then, each patient’s risk was assessed using the European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines, known as COMPERA and FPHR, and the Registry to Evaluate Early and Long-Term PAH Disease Management tools, the latest version of which is called REVEAL 2.0.

Physician risk assessment yielded risk profiles for the 153 patients that were weighted toward the low- and intermediate risk categories (41% and 46%, respectively), with just 13% of patients classified by physicians as high-risk. However, those assessments only matched the objective assessments about half the time (43%-54%). In fact, an estimated 4%-28% of patients characterized by physician gestalt as low-risk were later classified as high-risk by the objective methods. This came despite the fact that physicians believed their assessments were based on patient symptoms.

Having found the disparity between subjective and objective risk categorization, the investigators then set out to figure out the source of the incongruity. One factor stood out: the frequency of echocardiography. Physicians who ordered echocardiography every 7 to 12 months instead of every 3 months were more likely to have incongruities between their risk assessments and the objective multiparametric tools. Sahay and colleagues said they looked at other potential factors for risk incongruence, but no other associations were found.

The study was not designed to elucidate the clinical implications of variance between physician and objective risk evaluation, though Sahay and colleagues noted that 70% of physicians who underestimated risk cited patient stability over time as the reason for the incongruence.

“This is concerning because studies assessing risk have shown consistently that patients who remain at intermediate or high risk have poorer outcomes compared with patients whose PAH improves to achieve a lower risk profile,” the investigators wrote.

The authors concluded that their analysis “underscores the need for prospective prospective evaluation of risk assessment tools in the real-world setting.”


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.po