Challenges to Treating PH in Developing Countries Come With Opportunities, Review Asserts

Delayed diagnosis, limited resources, and a lack of awareness compound barriers to care for people with pulmonary hypertension (PH) in low- and middle-income countries, a recent review found.

The finding highlights the need for better patient advocacy across all levels of care, more affordable diagnostic tools, and improved awareness, particularly among healthcare practitioners.

The review study, “Pulmonary hypertension in majority countries: opportunities amidst challenges,” was published in Current Opinion in Pulmonary Medicine.

PH affects roughly 75 million people worldwide, 80% of whom live in low- and middle-income countries, also known as majority countries because they are  home to the majority of the world’s population.

Despite the high case numbers in these countries, resources such as targeted therapies and right heart catheterization — the “gold standard” for diagnosis and classification of PH — may be nonexistent. Even when they are available, they can prove too expensive for many patients to access.

Without enough tools to make accurate diagnoses, many cases likely go unreported. India and much of sub-Saharan Africa do not collect and keep high-quality records of PH cases, the review found. This probably leads to an underestimation of countries’ case loads.

This missing data means that data obtained from only a few places gets extrapolated to fill in the gaps. This happens despite the fact that both the burden and causes of PH are likely to vary widely across regions, nations, and even small provinces.

“Due to a lack of awareness about pulmonary hypertension in primary healthcare and gross under-diagnosis due to a lack of resources, the disease may be more prevalent than is frequently described in the literature,” the researchers wrote.

“Historically,” they continued, “the lack of awareness has been partnered with clinical nihilism, as appropriate therapies have either been unavailable or very expensive. This has driven physician interest away from pulmonary hypertension towards other conditions where outcomes are perceived to be better.”

This competition for resources and for the attention of medical professionals means that even in the best of settings, the signs of PH may go unnoticed until overt heart failure develops.

To the investigators, the challenges identified in their review imply significant opportunities.

Effective advocacy, for instance, could make the condition more visible and better understood, potentially triggering a shift in thinking about PH with optimism.

The lack of data concerning PH in majority countries represents a wealth of opportunities to investigate the condition. With so many undiagnosed cases in these developing countries, there is a high likelihood of finding unique cases and causes of the disorder that are rare in developed countries.

Having a better estimate of the true number of PH cases worldwide could reduce the global cost of PH therapies by improving their economies of scale, benefitting patients in developed and majority countries alike.

Finally, the reviewers argue that settings where access to investigations is limited, barriers to care could be lowered by testing practical and potentially noninvasive tools, such as algorithms looking at clinical data, for diagnosis and treatment.

“There is urgent need for pulmonary hypertension advocacy among clinicians in the primary, secondary and tertiary healthcare sectors of majority countries, and validated noninvasive diagnostic algorithms are needed,” the investigators wrote.

“Increased awareness and early diagnosis are likely to improve outcomes of pulmonary hypertension patients in these regions, and potentially stimulate locally relevant research,” they concluded.