Use of anticoagulants as a supportive measure in pulmonary hypertension: a narrative review

BACKGROUND: Pulmonary hypertension (PH) is a heterogeneous disorder with substantial morbidity and mortality. Thrombotic remodeling of pulmonary vasculature is a recognized contributor to disease progression, particularly in pulmonary arterial hypertension (PAH), prompting interest in anticoagulation as a potential adjunctive therapy. Despite the frequent use, anticoagulants continue to remain a controversial therapy across various subtypes of PH. METHODS: This review structurally evaluated published studies and evidence around the risks and benefits of anticoagulation across all five PH groups. Relevant peer-reviewed clinical trials, observational studies, and meta-analyses were identified through searches of PubMed, the Cochrane Library, and Google Scholar and were reviewed for survival outcomes, thromboembolic events, hemodynamics, and bleeding complications associated with anticoagulant use in PH. RESULTS: Evidence suggests that anticoagulation may provide a survival benefit in idiopathic PAH, while outcomes in connective tissue disease-associated PAH appear neutral or unfavorable due to increased bleeding risk. In other PH groups, anticoagulation has not demonstrated clear benefit and is generally reserved for standard indications such as atrial fibrillation or venous thromboembolism, except in chronic thromboembolic pulmonary hypertension, where it remains a cornerstone of therapy. Conclusion: There is currently no clear consensus on anticoagulation strategies across most pulmonary hypertension subtypes (except group 4). Given the heterogeneity of pulmonary hypertension, further well-designed prospective trials and PH-specific risk stratification tools are needed to clarify the role of anticoagulation and advance precision-based care in pulmonary hypertension.