Non specific drugs

Diuretics 
Diuretics are one of the most important treatments in the setting of PAH because right heart failure leads to fluid retention, hepatic congestion, ascites and peripheral edema. Right ventricular overload is part of clinical symptoms and has been associated with a poor prognosis in PAH [201]. Diuretics and salt-free diet relieve hypervolemia and associated symptoms. Whether this strategy improves prognosis is unknown. Dose adjustment of diuretics is needed, based on clinical and hemodynamic findings. Renal function and blood chemistry should be monitored to avoid renal failure or dyskalemia [192].

Oral anticoagulation 
Pathology specimens from PAH patients may show in situ thrombosis and thrombi recanalisation. Only few studies support anticoagulation treatment in PAH (mostly retrospective or not randomized) [202,203]. Current recommendations propose oral anticoagulation aiming for targeting an International Normalized Ratio (INR) between 1.5 and 2.5. Although the somewhat sparse evidence base is derived exclusively from idiopathic, heritable and PAH due to anorexigens, anticoagulation has been generalised to all patient groups, given the absence of contraindication. Anticoagulation is usually not recommended in porto-pulmonary hypertension because of the risk of esophageal variceal haemorrhage. In patients with systemic sclerosis, oral anticoagulation can be difficult to manage because of their high risk of bleeding, especially from the gastrointestinal tract. Variceal ligation is a preventive option in these cases. Long-term oral anticoagulation is essential in CTEPH with an INR which is recommended to be between 2 and 3.

Digitalis 
Digoxin has been suggested as part of PAH therapy in the past because it produces an acute increase in cardiac output [204], although its efficacy is unknown in PAH. Therefore it is usually proposed in PAH associated with atrial tachyarrhythmias [192].