2025 expert consensus on the use of parenteral prostanoids in incident and prevalent PAH patients: The Italian perspective

Background: The demographic shift of pulmonary arterial hypertension (PAH) patients, the expanding therapeutic armamentarium with new emerging drugs and the heterogenous experience in handling more complex therapies are making the management of PAH increasingly challenging. This project was developed to standardize PAH management across Italian centres and ensure timely access to the optimal therapeutic strategies. Methods: A consensus document containing 10 statements, mainly focused on the use of parenteral prostanoids, was developed by eight experts in PAH during in-person and web-based meetings. Forty-six physicians were invited online to rate each statement, indicating their agreement, neutrality or disagreement. Results: Forty physicians participated to the survey. There was strong agreement that age and comorbidities significantly influence the choice of PAH-targeted therapies. Agreement was also reached on the use of parenteral prostanoids in the following clinical scenarios: a) treatment-naive patients at high risk; b) newly diagnosed patients classified as intermediate-risk, with severe right ventricular dysfunction assessed invasively and c) prevalent high-risk patients, as defined by the 4-strata risk score. The use of parenteral prostanoids in selected newly diagnosed intermediate-risk patients with severe right ventricular dysfunction assessed by imaging achieved a mild agreement. Three statements did not meet the predefined threshold for consensus. Conclusions: These consensus statements are intended to support physicians in starting parenteral prostanoids, minimizing delays that could negatively affect patient prognosis.