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Chest. 2019 Mar;155(3):565-586. doi: 10.1016/j.chest.2018.11.030. Epub 2019 Jan 17.

Therapy for Pulmonary Arterial Hypertension in Adults: Update of the CHEST Guideline and Expert Panel Report.

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Brown University, Providence, RI.
Intermountain Healthcare and the University of Utah School of Medicine, Murray, UT.
University of Texas Health Science Center at San Antonio, San Antonio, TX.
A. Cardarelli Hospital, Naples, Italy.
OhioHealth/The Ohio State University, Columbus, OH.
University of South Alabama, Mobile, AL.
CHEST, Glenview, IL.
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
University of Utah, Salt Lake City, UT.
Columbia University Medical Center, New York, NY.
Children's Hospitals and Clinics of Minnesota, Minneapolis, MN.
Georgetown University Medical Center, Washington, DC.
University of Colorado School of Medicine, Aurora, CO. Electronic address:



Pulmonary arterial hypertension (PAH) carries a poor prognosis if not promptly diagnosed and appropriately treated. The development and approval of 14 medications over the last several decades have led to a rapidly evolving approach to therapy, and have necessitated periodic updating of evidence-based treatment guidelines. This guideline statement, which now includes a visual algorithm to enhance its clinical utility, represents the fourth iteration of the American College of Chest Physicians Guideline and Expert Panel Report on Pharmacotherapy for PAH.


The guideline panel conducted an updated systematic review to identify studies published after those included in the 2014 guideline. A systematic literature search was conducted using MEDLINE via PubMed and the Cochrane Library. The quality of the body of evidence was assessed for each critical or important outcome of interest using the Grading of Recommendations Assessment, Development and Evaluation approach. Graded recommendations and ungraded consensus-based statements were developed and voted on using a modified Delphi technique to achieve consensus.


Two new recommendations on combination therapy and two ungraded consensus-based statements on palliative care were developed. An evidence-based and consensus-driven treatment algorithm was created to guide the clinician through an organized approach to management, and to direct readers to the appropriate area of the document for more detailed information.


Therapeutic options for the patient with PAH continue to expand through basic discovery, translational science, and clinical trials. Optimal use of new treatment options requires prompt evaluation at an expert center, utilization of current evidence-based guidelines, and collaborative care using sound clinical judgment.


evidence-based medicine; guidelines; pulmonary arterial hypertension (PAH)

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