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Rethinking Pulmonary Arterial Hypertension: Ask the Expert

General Practice

Respiratory medicine

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Description

This program is supported by an independent educational grant from MSD. This online education program is designed solely for healthcare professionals in the USA. The content is not available for HCPs in any other country.

In this podcast episode, join Dr. Aaron Waxman, a leading voice in pulmonary vascular disease, and Dr. Christopher King, an expert in heart failure and pulmonary hypertension, for a deep dive into the rapidly evolving management of Pulmonary Arterial Hypertension (PAH). This session explores how to aggressively target low-risk status, the transition from monotherapy to upfront combination regimens, and the emergence of the "fourth pathway" in treatment. Whether you are navigating patient subjective improvement versus objective stability or managing real-world barriers like payer restrictions and comorbidities, this episode provides practical, evidence-based insights to optimize patient outcomes.

Credits: AMA PRA Category 1 Credits™ (0.25.00 hours)

Session Highlights

The Trap of "Feeling Better": Understand why subjective improvement can mask physiological progression and why regular, objective risk assessment is critical.
Escalation Triggers: Expert perspectives on when to escalate therapy, even for patients who appear clinically stable, using red flags like enlarged right atrium imaging or discordant hemodynamic results.
The Shift to Combination Therapy: Why upfront dual therapy is now the standard of care and how "stepwise" monotherapy is becoming an outdated paradigm.
The 4th Pathway: A look at activin signaling inhibition as a novel add-on therapy for patients failing to reach low-risk status on traditional vasodilators.
Navigating Real-World Barriers: Practical strategies for managing complex comorbidities (e.g., obesity), addressing payer restrictions, and communicating mortality risks to motivate patient adherence

Who Should Attend?

This program is for U.S. healthcare professionals involved in PAH care, including:

Pulmonologists
Cardiologists
Internal Medicine Physicians
Nurse Practitioners & Physician Assistants
Pharmacists
Nurses and other HCPs involved in the management of PAH

Faculty

Aaron B. Waxman, MD, PhD, FACP, FCCP

A distinguished leader in pulmonary vascular medicine, serving as the Executive Director of the Center for Pulmonary-Heart Diseases at Brigham and Women’s Hospital and an Associate Professor of Medicine at Harvard Medical School. With a dual background as a physician and researcher, Dr. Waxman has pioneered the use of invasive cardiopulmonary exercise testing to decode the complex relationship between the right heart and pulmonary vasculature.

Dr. Waxman is an author of over 150 peer-reviewed publications and a principal investigator on landmark clinical trials for therapies like Sotatercept, his work at the Dyspnea and Performance Evaluation Center continues to bridge the gap between benchside inflammatory research and bedside clinical excellence, earning him international recognition as a foremost expert in Pulmonary Arterial Hypertension (PAH).

Christopher S. King, MD

A Chief of Cardiovascular Critical Care at Inova Fairfax Hospital and the Associate Medical Director of the Transplant and Advanced Lung Disease Program. Board-certified in internal medicine, pulmonary medicine, and critical care, Dr. King brings over 24 years of clinical expertise to his roles as the Pulmonary Fibrosis Foundation Center Director and System Director of Respiratory Care Services for Inova.

An Associate Clinical Professor at the University of Virginia School of Medicine and a member of Alpha Omega Alpha, his distinguished career includes serving as a medical officer in the United States Army with tours in Korea and Afghanistan. A recognized researcher and panelist for the American College of Chest Physicians' antithrombotic guidelines, Dr. King’s work spans venous thromboembolism, interstitial lung disease, and pulmonary hypertension.

Continuing Education Information

Commercial support: This activity received monetary support through an independent education grant from MSD.

This continuing education activity will be provided by AffinityCE and MedAll. This activity will provide continuing education credit for physicians. A statement of participation is available to other attendees.

Disclosures

Dr Aaron B. Waxman has disclosed financial interests or relationships within the past 24 months with the following ineligible companies: Steering Committee Member for United Therapeutics and Merck, DSMB Chair for INSMED, and an Investigator for 35Pharma. These disclosures are provided in accordance with ACCME standards to ensure transparency and uphold the integrity of continuing education. Dr. Waxman does not intend to reference any unlabeled or unapproved uses of products during the presentation.

Dr Christopher King has disclosed financial interests or relationships within the past 24 months with the following ineligible companies: Speaker for United Therapeutics, and member of Advisory Boards for United Therapeutics and Merck. These disclosures are provided in accordance with ACCME standards to ensure transparency and uphold the integrity of continuing education.

Dr King intends to discuss non-FDA uses of drug products and/or devices only in relation to products for which he has no financial relationships. He will disclose to the audience when this discussion takes place.

AffinityCE staff, MedAll staff, as well as planners and reviewers, have no relevant financial relationships with ineligible companies to disclose.

Mitigation of Relevant Financial Relationships

AffinityCE adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CME activity, including faculty, planners, reviewers, or others, are required to disclose all relevant financial relationships with ineligible companies. Relevant financial relationships were mitigated by the peer review of content by non-conflicted reviewers prior to the commencement of the program.

Activity Accreditation for Health Professions

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physician assistants should claim only the credit commensurate with the extent of their participation in the activity.

Nurse Practitioners

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Nurse practitioners should claim only the credit commensurate with the extent of their participation in the activity.

Nurses & Other Professionals

All other health care professionals completing this continuing education activity will be issued a statement of participation indicating the number of hours of continuing education credit. This may be used for professional education CE credit. Please consult your accrediting organization or licensing board for their acceptance of this CE activity.

System Requirements

Mobile device (e.g., large-format smart phone; laptop or tablet computer) or desktop computer with a video display of at least 1024 × 768 pixels at 24-bit color depth, capable of connecting to the Internet at broadband or faster speeds, with a current version Internet browser and popular document viewing software (e.g., Microsoft Office, PDF viewer, image viewer) installed. Support for streaming or downloadable audio-visual materials (e.g., streaming MP4, MP3 audio) in hardware and software may be required to view, review, or participate in portions of the program.

Unapproved and/or off-label use disclosure

AffinityCE/MedAll requires CE faculty to disclose to the participants:

When products or procedures being discussed are off-label, unlabeled, experimental, and/or investigational (not US Food and Drug Administration [FDA] approved); and
Any limitations on the information presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.

CME Inquiries

For all CME policy-related inquiries, please contact us at ce@affinityced.com.

Participation Costs

There is no cost to participate in this program.

This continuing education activity is available from the 18th of March 2026 and will expire on June 28th 2027.

Estimated time to complete this activity: 15 minutes.

Disclaimer

This activity is intended for educational purposes only and does not establish a standard of care or replace clinical judgment. Any therapeutic or diagnostic strategies discussed must be evaluated in the context of each patient’s clinical circumstances, risks, and current evidence.

Learners should consult authoritative clinical guidelines and approved product information when considering treatment decisions.

All materials are used with permission. The views expressed are those of the faculty and do not necessarily reflect those of the accredited providers, MedAll, or any supporters.

Content is accurate as of the date of release.

Learning objectives

Upon completion of this activity, participants should be better able to:

Describe the major pathophysiological pathways underlying PAH and how they inform therapeutic targets.
Apply current international guideline recommendations to ensure evidence-based use of approved PAH therapies.
Differentiate between monotherapy, dual therapy, and triple therapy approaches, highlighting their appropriate use in clinical practice.
Determine when and how to escalate therapy in patients with PAH, using risk stratification and clinical response to guide treatment intensification.
Develop personalized treatment plans that integrate guideline-directed therapy, pathway-based rationale, and patient-specific factors to optimize outcomes.

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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello and welcome to Rethink Pulmonary arterial hypertension. Ask the expert. I'm your host, Gabriel Maria, and today we're diving deep into the evolving landscape of pulmonary arterial hypertension management. We're moving beyond the traditional wait and see approach and discussing how to aggressively target low-risk status for our patients. Today I'm joined by two distinguished experts, Doctor Aaron Waxman, a leading voice in pulmonary vascular disease, and Doctor Christopher King, an expert in heart failure and pulmonary hypertension. Doctors, thank you for being here. Thank you for having us. Yes, hello. Let's jump right in. Doctor Waxman, a common scenario clinicians face is the patient who says they're feeling better after starting therapy. Is subjective improvement a trap? And if so, how often should we be formally reassessing risk? I think one of the important things to subjective improvement often is lacking. This is a very slowly progressive disease, so patients tend to adapt well to their shortness of breath, and oftentimes from a subjective standpoint it means really bringing family members or friends in to ask how they are doing as well, are they waiting for them to catch up. As part of that, I think the objective assessment needs to be done fairly frequently when someone is just starting out the therapeutic pathway. So generally for us that's at least every 3 months until we start to see real clear findings of improvement. We also want to be assessing risk category over the same time frame, which combines some subjective as well as objective improvement. I think for us, we want to see all of our patients become a functional class one, and just being intermediate or low risk is not good enough, but certainly it's improvement, depending on where that patient started, um, and really doing a series of testing, both, uh, exercise testing, exercise tolerance, blood testing with proBNP, um. And just getting a sense of how a patient is doing and then on top of that echoes at certain time points. Dr. King, let's make this concrete. We often see patients who improve functionally but still have concerning imaging. For example, a 42-year-old patient who improves to functional class 2 but still has an enlarged right atrium on echo. What is your trigger for escalation in a case like that? No, I think it's an important point. Uh, you know, it, it's certainly gratifying when you see patients improve from a functional standpoint, and, and, um, I think, uh, the, the right ventricular function though is very closely tied with their overall outcome. And so even in patients, uh, that have an improvement in their functional class and, uh, and BNP, if they still have a significant RV dilatation or right atrial dilatation, uh, in those patients, I would be more aggressive in augmenting their therapy. And so, I think taking into consideration, um, as Doctor Waxman mentioned, you know, their, their imaging finding is, is very important. Moving to treatment strategies, Doctor Waxman, we hear that the stepwise approach, starting one drug and waiting, could now be considered outdated. Can you walk us through the current thinking of upfront combination therapy versus sequential addition? Sure, and I would agree that the stepwise approach is outdated at this point. I think I like to think of it more as almost a chemotherapeutic approach where we start multiple drugs at the outset and see how the patient does, and that gets to a risk categorization approach, whereas if they're high or intermediate high, we're going to start at least 3 drugs at that point. And see how they do in a short time frame, and by that I mean relatively short 3 months. And if they're not improving, then we may want to add on a 4th agent which right now would be an activein inhibitor. It's a very rare patient at this point who would start with a single drug. Maybe that would be an exercise pH patient, but I think at this point triple therapy upfront and then de-intensifying therapy as that patient improves is the best strategy. Dr. King, we now have a 4th pathway to consider active in signaling inhibition with cetatracept. How does this fit into the treatment algorithm? When are you reaching for this 4th agent? My current, um, strategy with, uh, use of sertaricept is involved, you know, taking these patients that are on, um, triple therapy and, and maybe in an intermediate risk, uh, category and, and using it as an additional agent and, and, or for patients that have progressive disease that, um, you know, in the past, we might have considered, uh, escalation to parenteral proscinoids, things like that. Although I have to say, like, as time goes on, and we get more and more Um, experience with the medication and, uh, and comfort with, uh, certatercept. I think the, um, the number of patients that we're putting on this therapy are expanding, and I think over time, we may evolve to a point where certatercept is almost the, the background therapy for all of these patients. I, I, you know, I think further clinical trials will help us determine that, or at least, uh, registry data as people sort of, uh, expand their off-label use of the medication. Um, but, you know, because of the potential for sort of remodeling and, and, um, and disease modification, um, I, I, I do think that we'll see an expanding role, um, beyond this sort of, uh, use in, in kind of an intermediate or, or high-risk patients. Let's tackle the real world barriers. Dr. Waxman, comorbidities are a huge challenge. How do you manage a patient who needs aggressive pulmonary arterial hypertension therapy, but has severe obesity or other issues that complicate the picture? Yeah, I think all of these patients come with some sort of comorbidity. It's a very rare patient that that is a true idiopathic PAH or doesn't overlap from one group to the other. I think there's an increasing role for SGLT-2 and GLP-1 agonists in those patients with BMIs that are higher than they should be. I would also add that as our patients are getting older, they often will have overlapping. Physiology consistent with group 2 disease and there 2 SGLT-2 inhibitors are playing an increasing role. from a transplant standpoint. The truth is with activin inhibitors and we're looking at the 2nd generation of those drugs now coming down the pipeline. The 2nd generation actually has overlap with both vascular remodeling as well as improving lean body maps. So it may be we'll have a single drug in combination with our pulmonary vasodilators that will tackle several aspects of comorbidities. It's increasingly rare that I'm sending a patient for transplant at this point with aggressive management and for drug management, so. I think we're moving into a realm of disease modification in combination with some of these other agents. Finally, Doctor King, we often face payer restrictions or patient hesitancy when trying to add a 3rd or 4th drug. How do you navigate these conversations? Um, you know, I, I do think insurance companies can sometimes, uh, pull somewhat of a barrier. I, we try to emphasize the, uh, the need for, um, multiple, um, therapeutic agents in these patients, and, uh, a lot of times with, um, You know, letters that sort of appeal letters that explain uh the rationale and, and quoting the the literature like ambition trial, etc. uh, we can, we can get these medications covered. Um, and I think over time, um, there, uh, payers have sort of increasingly recognized the The need for, uh, multiple therapeutics. And it's, it's similar to other disease states like congestive heart failure, uh, where, where we use multiple agents in a single disease state to hit different pathways. And so, I do think, um, you know, it's, um, hopefully, we become less and less of a barrier over time. Doctor, this has been an incredibly practical discussion. To summarize, subjective improvement is not enough. We need objective risk assessment. Upfront combination therapy is the standard, and we should consider triple or quadruple therapy to get our patient to low risk status. Doctor Baxman, Doctor King, thank you for sharing your expertise. Thank you. Thanks very much. Yes, thank you for having me. To our listeners, thank you for joining us. You can find the full rethink pulmonary arterial hypertension curriculum, including the downloadable infographic targeting the pathways at medalleducation.com. Please complete the feedback form there to receive your free CME certificate.