Commentary on the guidelines (2022) of the ESC/ERS on the diagnosis and treatment of pulmonary hypertension

Pulmonary hypertension (PH) is a frequent condition occurring in approximately 1% of the global population, which is associated with considerable morbidity and mortality, irrespective of the underlying cause. The pathophysiology is complex and may involve several organ systems, requiring a multidisciplinary approach to management. The updated 2022 guidelines of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) on the diagnosis and treatment of pulmonary hypertension provide numerous substantial modifications and emphasize the relevance of the clinical classification of PH (groups 1-5) and a thorough differential diagnostic work-up as the therapeutic strategies for the various forms of PH are fundamentally different. Important changes include: (i) modified hemodynamic definitions of PH (general definition, precapillary vs. postcapillary PH, isolated postcapillary PH, IpcPH, combined postcapillary and precapillary PH, CpcPH), (ii) diagnostic approach including a refurbished diagnostic algorithm and specific recommendations for echocardiography and right heart catheterization, (iii) innovations on the management of pulmonary arterial hypertension (PAH; group 1) with a newly structured treatment algorithm, modified risk stratification (3 strata, 4 strata) and consideration of distinct phenotypes ("PAH with comorbidities"), (iv) detailed recommendations for the management of PH associated with left heart diseases (group 2) or lung diseases (group 3), (v) specific aspects of chronic thromboembolic pulmonary hypertension (CTEPH; group 4) including a distinct diagnostic algorithm and a multimodality approach to treatment. Finally, the ESC/ERS guidelines define criteria for specialized PH expert centers and for multidisciplinary teams (MDT). This commentary focus on the most important changes compared to the 2015 ESC/ERS guidelines and on the practical implementation of the updated guidelines in Germany.