@article{3200779,
    title = "Aggressive Afterload Lowering to Improve the RV: A New Target for Medical Therapy in PAH?",
    author = "Vizza, Carmine Dario and Lang, Irene M. and Badagliacca, Roberto and Benza, Raymond L. and Rosenkranz, Stephan and White, R. James and Adir, Yochai and Andreassen, Arne K. and Balasubramanian, Vijay and Bartolome, Sonja and Blanco, Isabel and Bourge, Robert C. and Carlsen, Jørn and Conde Camacho, Rafael Enrique and D'Alto, Michele and Farber, Harrison W. and Ford, H. James and Frantz, Robert P. and Ghio, Stefano and Gomberg-Maitland, Mardi and Humbert, Marc and Naeije, Robert and Orfanos, Stylianos E. and Oudiz, Ronald J. and Perrone, Sergio V. and Shlobin, Oksana A. and Simon, Marc A. and Sitbon, Olivier and Torres, Fernando and Vachiery, Jean Luc and Wang, Kuo-Yang and Yacoub, Magdi H. and Liu, Yan and Golden, Gil and Matsubara, Hiromi",
    journal = "AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE",
    year = "2021",
    issn = "1073-449X",
    doi = "10.1164/rccm.202109-2079PP",
    keywords = "combination therapy, prostacyclin, pulmonary arterial hypertension, pulmonary arterial pressure, right ventricular afterload",
    abstract = "Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median  age of 50 years. This article explores whether early, robust reduction of right  ventricular afterload would facilitate substantial improvement in right ventricular  function and thus whether afterload reduction should be a treatment goal for  pulmonary arterial hypertension. The earliest clinical studies of prostanoid  treatment in pulmonary arterial hypertension demonstrated an important link between  lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and  improved survival. Subsequent studies of oral monotherapy or sequential combination  therapy demonstrated smaller reductions in mean pulmonary arterial pressure and  pulmonary vascular resistance. More recently, retrospective reports of initial  aggressive prostanoid treatment or initial combination oral and parenteral therapy  have shown marked afterload reduction along with significant improvements in right  ventricular function. Some data suggest that reaching threshold levels for pressure  or resistance (components of right ventricular afterload) may be key to interrupting  the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial  hypertension and could translate into improved long-term clinical outcomes. Based on  these clues, the authors postulate that improved clinical outcomes might be achieved  by targeting significant afterload reduction with initial oral combination therapy  and early parenteral prostanoids. This article is open access and distributed under  the terms of the Creative Commons Attribution Non-Commercial No Derivatives License  4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)."
}