Pulmonary Arterial Hypertension and Endothelial Dysfunction

Pulmonary hypertension is a progressive and multifactorial disorder associated with a broad spectrum of cardiovascular and respiratory conditions. The updated definition proposed at the World Symposium on Pulmonary Hypertension (mean pulmonary arterial pressure 20 mmHg, pulmonary arterial wedge pressure ≤15 mmHg, and pulmonary vascular resistance ≥3 Wood units) has improved diagnostic sensitivity, enabling earlier recognition of disease onset and progression. This review discusses the central role of endothelial dysfunction in pulmonary vascular homeostasis and examines the dynamic interplay between pulmonary arterial smooth muscle cells and the extracellular matrix under both physiological and pathological conditions. Key mechanisms underlying vascular remodeling, including intimal proliferation, medial hypertrophy, and extracellular matrix reorganization, are explored as major contributors to increased pulmonary vascular resistance and right ventricular overload. Experimental models of pulmonary hypertension are critically evaluated regarding their translational relevance, methodological strengths, and limitations in reproducing human disease phenotypes. In addition, current evidence-based therapeutic strategies are appraised in the context of recent randomized clinical trials, with emphasis on risk stratification and disease-targeted interventions. Finally, emerging experimental therapies and novel translational approaches are discussed, highlighting future perspectives for precision medicine and advanced vascular-targeted treatments in pulmonary hypertension.