**Purpose**: We propose an alternative approach to the
extensively validated REVEAL risk score calculator using Bayesian network (BN)
modeling. We derived a BN model with the same variables and discretization cut
points as the REVEAL risk score calculator and data from the REVEAL registry.
This study compared the performance and relative impact of the variables in the
two PAH risk assessment tools.

**Methods**: 2,456 adult patients from the REVEAL
registry were used to develop a Bayesian network model to predict 1-year
survival using the Tree Augmented Naive Bayes (TAN) algorithm. We used 10-fold
cross validation to measure the BN performance, reported as the area under the
receiver operating characteristic curve (AUC). We compared hazard ratios of the
variables in the REVEAL calculator to the cross entropy in the Bayesian network.
The cross-entropy measures how much the variables influence the outcome.

**Results**: The BN model demonstrated an AUC of 0.77 for
predicting one-year survival. This was an improvement to the existing AUC of
0.71 for the original REVEAL calculator. There is a high correlation (r =
0.786) for the hazard ratio and the cross entropy, when all risk factors are
absent (Figure 1a). In the same context of variables, the cross-entropy and the
hazard ratio capture the similar influences to the outcome. However, when the
risk factors are partially known for a given patient (Figure 1b), the cross-entropy
changes based on the context of which risk factor are observed.

**Conclusion**: BN demonstrated a modest improvement in performance
over the REVEAL 1.0 model. Moreover, it improved the understandability of the
relationship between risk factors, the dynamic influences of each risk factor,
and challenges the assumption of independence between risk factors.