"Pulmonary hypertension in Saudi Arabia: A single center experience," which was published in the previous issue of Annals of Thoracic Medicine.

Sir,

We read with great interest the article by Alhamad et al.,[1] entitled “Pulmonary hypertension in Saudi Arabia: A single center experience,” which was published in the previous issue of Annals of Thoracic Medicine.

The authors are to be congratulated for publishing the first comprehensive data about pulmonary hypertension (PH) in Saudi Arabia.

However, two points are worth commenting upon.

First, the authors had submitted 264 patients with suspected PH to invasive right heart catheterization. Out of those, only 152 studies were diagnostic (57.6%). The screening method used by the authors has depended upon suspicion of PH on clinical examination, when a marked reduction in the predicted DLCO <40% was noted, when oxygen desaturation <88% was evident during the 6-min walk test, or when indicated by the results of chest radiography, computed tomography, and/or echocardiography. Being that significant number of enrolled patients (49.3%) had belonged to World Health Organization group III disease (mostly interstitial lung disease in this study), such screening criteria were proved to be very insensitive and lead to over studying these patients invasively.

Second, the authors have shown their practice in treating all PH groups (except group II) by pulmonary arterial hypertension (PAH) specific therapy. Many of studies have shown conflicting results regarding the efficacy and safety of using PAH drugs in non-PAH patients[2345] and all clinical guidelines and drug regularity authorities have asked for enrolling patients in clinical trials before subjecting those patients to this class of therapy. Until date, such therapy has not been approved for the treatment of non-PAH groups, including PH groups III and V. Hence, we wonder whether the patients studied by the authors in this particular study were actually enrolled in controlled trials or this indeed reflected the authors’ practice.

In conclusion, the study by Alhamad et al., was very interesting, and to be considered as a great initiative effort in describing PH management in Saudi Arabia; however, we believe that treating this very complex disease need to be comprehensive and should be always obligated to the international guidelines recommendations.[6]