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Abstract Rationale: Pulmonary hypertension (PH) complicating interstitial lung disease (ILD-PH) has a poor prognosis. Despite significant morbidity associated with ILD-PH, there are no evidence-based screening recommendations for PH in the setting of ILD. The PHINDER study (NCT05776225) aims to develop a PH screening tool in patients with ILD. PH is confirmed in all patients by right-heart catheterization (RHC). This analysis compares clinicians’ gestalt of PH with hemodynamically confirmed PH. Methods: PHINDER is a prospective, multicenter study intending to enroll 200 ILD patients who are suspected to have PH. Patients receive study clinical assessments followed by right heart catheterization (RHC). Precapillary ILD-PH is defined by 2022 ESC/ERS guidelines: mean pulmonary arterial pressure >20 mmHg, pulmonary artery wedge pressure ≤15 mmHg, and pulmonary vascular resistance >2 Wood Units. Prior to the RHC, clinicians are required to document their gestalt-based suspicion of PH (low, medium, high). Results: Data were available for 58 patients at this interim analysis (Table 1). There were 8, 27, and 23 patients at low, medium, and high suspicion of PH, respectively. In these 3 groups, 4 (50%), 11 (41%), and 14 (61%) of patients respectively met the hemodynamic definition of precapillary ILD-PH. Conclusions: Findings suggest that patients with higher suspicion of PH (gestalt based) had lower 6-minute walk distance, increased supplemental oxygen use, increased right ventricle systolic pressure and decreased tricuspid annular plane systolic excursion (TAPSE) on echocardiography, and an enlarged pulmonary artery (PA) on HRCT. Increased forced vital capacity to diffusing capacity (FVC/DLCO) ratio, decreased DLCO, decreased TAPSE/systolic PA pressure ratio, and enlarged PA were more pronounced among patients with RHC-confirmed PH in all 3 suspicion groups, suggesting that these parameters may be useful to clinicians assessing risk of PH. Surprisingly, brain natriuretic peptide (BNP) and N-terminal proBNP do not seem prognostic of PH thus far in the study. Physical exam findings did not correlate well with either clinical suspicion of PH or RHC-confirmed PH. Even with low clinical suspicion (a situation in which clinicians may not obtain a RHC), PH may be missed in 50% of patients. Results of this analysis underscore the difficulty in using clinical gestalt alone to assess the risk of PH.

OBJECTIVES:To determine the association of prior use of renin-angiotensin-aldosterone system inhibitors (RAASIs) with mortality and outcomes in hospitalized patients with COVID-19.DESIGN:Retrospective observational study.SETTING:Multicenter, international COVID-19 registry.Subjects:Adult hospitalized COVID-19 patients on antihypertensive agents (AHAs) prior to admission, admitted from March 31, 2020, to March 10, 2021.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Data were compared between three groups: patients on RAASIs only, other AHAs only, and those on both medications. Multivariable logistic and linear regressions were performed after controlling for prehospitalization characteristics to estimate the effect of RAASIs on mortality and other outcomes during hospitalization. Of 26,652 patients, 7,975 patients were on AHAs prior to hospitalization. Of these, 1,542 patients (19.3%) were on RAASIs only, 3,765 patients (47.2%) were on other AHAs only, and 2,668 (33.5%) patients were on both medications. Compared with those taking other AHAs only, patients on RAASIs only were younger (mean age 63.3 vs 66.9 yr; p < 0.0001), more often male (58.2% vs 52.4%; p = 0.0001) and more often White (55.1% vs 47.2%; p < 0.0001). After adjusting for age, gender, race, location, and comorbidities, patients on combination of RAASIs and other AHAs had higher in-hospital mortality than those on RAASIs only (odds ratio [OR] = 1.28; 95% CI [1.19–1.38]; p < 0.0001) and higher mortality than those on other AHAs only (OR = 1.09; 95% CI [1.03–1.15]; p = 0.0017). Patients on RAASIs only had lower mortality than those on other AHAs only (OR = 0.87; 95% CI [0.81–0.94]; p = 0.0003). Patients on ACEIs only had higher mortality compared with those on ARBs only (OR = 1.37; 95% CI [1.20–1.56]; p < 0.0001).CONCLUSIONS:Among patients hospitalized for COVID-19 who were taking AHAs, prior use of a combination of RAASIs and other AHAs was associated with higher in-hospital mortality than the use of RAASIs alone. When compared with ARBs, ACEIs were associated with significantly higher mortality in hospitalized COVID-19 patients.

While the general term "burnout" is used to describe many of the challenges of contemporary medical training, a more precise characterization that unifies these challenges is a deficiency of the virtue of hope. Medical trainees face many obstacles to the cultivation of hope during training, but learning both to correctly identify this deficiency, and practices which prove a fitting response, offers a way forward.

High bleeding risk (HBR) patients undergoing percutaneous coronary intervention have been widely excluded from randomized device registration trials. The LF study (LEADERS FREE) reported superior outcomes of HBR patients receiving 30-day dual antiplatelet therapy after percutaneous coronary intervention with a polymer-free drug-coated stent (DCS). LFII was designed to assess the reproducibility and generalizability of the benefits of DCS observed in LF to inform the US Food and Drug Administration in a device registration decision. LFII was a single-arm study using HBR inclusion/exclusion criteria and 30-day dual antiplatelet therapy after percutaneous coronary intervention with DCS, identical to LF. The 365-day rates of the primary effectiveness (clinically indicated target lesion revascularization) and safety (composite cardiac death and myocardial infarction) end points were reported using a propensity-stratified analysis compared with the LF bare metal stent arm patients as controls. A total of 1203 LFII patients were enrolled with an average 1.7 HBR criteria per patient, including 60.7% >75 years of age, 34.1% on anticoagulants, and 14.7% with renal failure. Propensity-adjusted 365-day clinically indicated target lesion revascularization was significantly lower with DCS (7.2% versus 9.2%; hazard ratio, 0.72 [95% CI, 0.52-0.98]; P=0.0338 for superiority), as was the primary safety (cardiac death and myocardial infarction) composite (9.3% versus 12.4%; hazard ratio, 0.72 [95% CI, 0.55-0.94]; P=0.0150 for superiority). Stent thrombosis rates were 2.0% DCS and 2.2% bare metal stent. Major bleeding at 1 year occurred in 7.2% DCS patients and 7.2% bare metal stent. LFII reproduces the results of the DCS arm of LF in an independent, predominantly North American cohort of HBR patients.

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