Delays in the diagnosis and management of pulmonary arterial hypertension: a simulated patient cases study across four European countries.

Background: Pulmonary arterial hypertension (PAH) is progressive and underdiagnosed, contributing to high morbidity and mortality. We assessed physicians' diagnostic accuracy and management practices using simulated PAH cases across four European countries. Methods: A cross-sectional online survey (June-August 2024) enrolled 230 consultant cardiologists, pulmonologists and rheumatologists from Germany, Italy, Spain and Portugal. Each completed three simulated PAH cases, representing idiopathic and connective tissue disease (CTD)-associated presentations. Outcomes were correct diagnosis, appropriate referral and adherence to 2022 European Society of Cardiology/European Respiratory Society guideline-recommended management. Results: Across all 386 cases, the correct diagnosis was made in 49% (190/386). Diagnostic accuracy was higher for idiopathic presentations (59% (80/135)) than CTD-associated presentations (44% (110/251)). Guideline-adherent management occurred in 33% of cases. Among those correctly diagnosing pulmonary hypertension (PH), 32% of physicians failed to follow appropriate referral or testing pathways. Echocardiography was requested in 92% of cases (354/386), but PH was accurately diagnosed in only 52% of those. Physicians in Portugal demonstrated significantly superior diagnostic and management accuracy compared with other countries. Physicians with fewer years of experience (2-10 years) achieved greater diagnostic accuracy than more experienced colleagues. Conclusions: These findings indicate persistent diagnostic and management variability across four European countries, especially for CTD-associated presentations, and suggest that enhanced echocardiographic training and clearer referral pathways could improve diagnostic accuracy and guideline-adherent care.