To stress or not to stress? : exercise pulmonary haemodynamic testing in systemic sclerosis

Pulmonary arterial hypertension (PAH) is a leading cause of morbidity and mortality in systemic sclerosis(SSc) [1], and patients have a ∼10% lifetime risk of developing this devastating complication [2]. Despite targeted PAH therapy, outcomes of SSc-associated PAH (SSc-PAH) remain unsatisfactory, with a median survival of only 3-4 years from time of diagnosis [3, 4]. In the hope of further improving outcomes in SSc-PAH, early disease detection has been a major focus of research in the past decade [5-9]. One important and highly debated topic is the utility of exercise pulmonary haemodynamic testing for the early diagnosis of pulmonary vascular disease [10-12].