During the early 2020s, many have been struck by how quickly the world embraced the severe restrictions that came with the announcement of the COVID-19 pandemic; this was probably coupled with surprise 2 years later with the seemingly nonchalant manner in which society returned to normal, like a rubber band snapping back into place after it has been stretched to its limits. 

The COVID-19 pandemic has been a peculiar time, to say the least; it was as if the rules of modern living were temporarily suspended, with mostly willing participation by the masses. The world was all at once tunnel-focused on a specific respiratory-driven illness, and the attention held over months and years. 

During this difficult time, many appeared to become acutely aware of their own mortality, and consciously or not, people were working out in their heads their odds of surviving the pandemic. Has the latest vaccine been taken? Check. Are there comorbidities that might contribute to a more severe disease course? Maybe. Has human interaction been limited to a bare minimum? Yes, indeed. 

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There is little doubt that this period of human history will be dissected, studied, romanticized, and parodied in the decades to come. However, there are important lessons that need to be learned, and this pandemic has provided clinicians with ample data on managing comorbidities in an acute environment that could not have been obtained any other way. 

Managing COVID-19 With a Preexisting Respiratory Illness 

First, we must acknowledge that there was considerable anxiety among medical professionals about treating patients with COVID-19 who had comorbidities, particularly rare ones that we know little about, such as pulmonary arterial hypertension (PAH), for example. 

It is important that we continue to pay tribute to the brave healthcare workers who worked tirelessly during a very perplexing, painful time. The use of personal protection equipment during contact with patients with COVID-19 was exhausting as the suits were often unbearably stifling and had to be worn for hours at a time. Government policies changed, sometimes seemingly on a whim, and family members were often locked out of personally interacting with patients who they knew.

Read more about PAH etiology

Let’s discuss how clinicians approached treating patients with COVID-19 with preexisting PAH. 

“Patients with PAH could be at increased risk for complications and, subsequently, worse outcomes following COVID-19,” Farmakis and Giannakoulas wrote in Heart Failure Clinics.

A plethora of studies have assessed the prognosis of patients with PAH who have contracted COVID-19, the general consensus being that PAH was only significantly more dangerous if patients had other comorbidities (such as diabetes, obesity, and cardiac disease). The risk of morbidity and mortality also increased if a patient was frail or elderly.

Regarding management, physicians typically continued prescribing PAH-targeted drugs. The goal was to ensure that oxygen saturation remained higher than 90%; a high-flow nasal cannula was often used to achieve this goal. In addition, physicians made it a habit to advise their patients to get vaccines when they become available, as vaccines could prevent some of the more disabling complications of COVID-19. 

Real-World Treatment of PAH and COVID-19 

“Early in the pandemic, there was speculation in the pulmonary vascular community regarding a perceived low risk for severe COVID-19 in patients with pulmonary arterial hypertension,” Farha and Heresi wrote in the Annals of the American Thoracic Society. 

This anecdotal observation prompted many questions and theories as to why this was the case. Some clinicians proposed that PAH-specific medications were protective against COVID-19; in addition, angiotensin-converting enzyme 2 (ACE-2), which was instrumental for the entrance of the COVID-19 virus into cells, was downregulated in patients with PAH. 

However, further analysis demonstrated that there was more below the surface. For example, although the prevalence of COVID-19 cases among patients with PAH was similar to that of the general population, outcomes were worse, with an approximately 50% rate of hospitalization and 12% mortality rate with patients with both PAH and COVID-19. These observations demonstrated that PAH was still a liability in the fight against COVID-19. 

Clinicians working in real-world settings during the pandemic also reported a massive change in how PAH care was administered. Because any visit to the hospital or healthcare facility was discouraged during the pandemic, much of PAH care was shifted toward telehealth and home care. There was also a decrease in the initiation of PAH-related therapies and lung transplant referral. 

Read more about PAH treatment

In other words, amid the whispers of anecdotal observations and conflicting reports about whether some comorbidities helped or hurt the course of COVID-19 disease, a picture eventually emerged in which it was clear that PAH was a liability, a comorbidity that represented a new layer of challenge in the acute care of sick individuals with COVID-19. 

The authors of this study, writing in 2020, spoke about the oft-repeated strategies to minimize the spread of COVID-19: wearing a face mask, frequent hand washing, and social distancing, and these measures undoubtedly helped. 

Given that the acute phase of the pandemic is behind us, it behooves us to ask: what can we learn about COVID-19 and PAH? First, all comorbidities when present in a concurrent novel infection are unlikely to be helpful. Second, in pandemic conditions, physicians need to find innovative ways to treat patients when there is no playbook available. However, with an eye on the future, clinicians can gather crucial data, right in the eye of the storm, that can be of use in answering the questions that remain. 


Farmakis IT, Giannakoulas G. Management of COVID-19 in patients with pulmonary arterial hypertensionHeart Fail Clin. 2023;19(1):107-114. doi:10.1016/j.hfc.2022.07.003

Farha S, Heresi GA. COVID-19 and pulmonary arterial hypertension: early data and many questionsAnn Am Thorac Soc. 2020;17(12):1528-1530. doi:10.1513/AnnalsATS.202008-1014ED