RATIONALE: Pulmonary (arterial) hypertension (PH/PAH) is a life-threatening cardiopulmonary disorder where inflammation and immunity have emerged as critical early pathogenic elements. Although pro-inflammatory processes in PH/PAH are the focus of extensive investigation, the initiating mechanisms remain elusive. OBJECTIVES: We tested whether activation of the complement cascade is critical in regulating pro-inflammatory and pro-proliferative processes in the initiation of experimental hypoxic PH, and can serve as a prognostic biomarker of outcome in human PAH. METHODS: We employed immunostaining of lung tissues from experimental PH models and PAH patients; analyses of genetic murine models lacking specific complement components or circulating immunoglobulins; cultured human pulmonary adventitial fibroblasts; and network medicine analysis of a biomarker risk panel from plasma of PAH patients. MEASUREMENTS AND MAIN RESULTS: Pulmonary perivascular-specific activation of the complement cascade was identified as a consistent critical determinant of PH/PAH in experimental animal models and humans. In experimental hypoxic PH, pro-inflammatory and pro-proliferative responses were complement (Alternative pathway and C5)-dependent, and immunoglobulins, particularly IgG, were critical for activation of the complement cascade. We identify Csf2/GM-CSF as a primary complement-dependent inflammatory mediator. Furthermore, using network medicine analysis of a biomarker risk panel from plasma of PAH patients, we demonstrate that complement signaling can serve as a prognostic factor for clinical outcome in PAH. CONCLUSIONS: The present study establishes immunoglobulin-driven dysregulated complement activation as a critical pathobiological mechanism regulating pro-inflammatory/pro-proliferative processes in the initiation of experimental hypoxic PH, and demonstrates complement signaling as a critical determinant of clinical outcome of in PAH.