PH‐ILD carries a poor prognosis, particularly with PVR > 5 WU. The INCREASE trial demonstrated the successful use of inhaled treprostinil, but slow uptitration delays the effects. Our study suggests outpatient IV dobutamine as interim support, improving contractility and reducing PVR during uptitration.

Background: Treprostinil has demonstrated effectiveness in treating Pulmonary Arterial Hypertension (PAH) and Pulmonary Hypertension associated with Interstitial Lung Disease (PH-ILD). However, tolerability remains a clinical challenge. Identifying factors influencing tolerability is important, given the adverse outcomes of PAH and PH-ILD and the potential of treprostinil to slow disease progression. Objective: This study was undertaken to identify tolerance factors and develop a predictive scoring system. Methods: A retrospective analysis of 65 patients (37 PAH, 28 PH-ILD) was conducted using patient history, pulmonary function tests (PFTs), transthoracic echocardiograms (TTEs), and right heart catheterizations (RHCs). Of these, 67.7% (n = 44) tolerated treprostinil, while 32.3% (n = 21) were intolerant. Results: Patients who tolerated treprostinil had better pulmonary function, with a higher forced expiratory volume in one second/forced vital capacity (FEV₁/FVC) ratio (82.27 ± 16.06 vs. 72.86 ± 17.76, p = 0.037) and superior right ventricular function, as indicated by higher tricuspid annular plane systolic excursion (TAPSE: 2.05 ± 0.37 vs. 1.64 ± 0.42, p < 0.001), higher cardiac index (CI: 2.51 ± 0.67 vs. 2.03 ± 0.53, p = 0.003), and improved functional status (p < 0.001). The Inhaled Treprostinil Intolerance Score (ITIS), incorporating TAPSE < 1.6, CI < 2, FEV₁/FVC < 70%, and WHO functional class (FC) 3 or 4, demonstrated strong predictive accuracy (cutoff ≥ 2, AUC = 0.884 ± 0.048, p < 0.001). Predictive performance was stronger in PAH patients (AUC = 0.921 ± 0.053) than PH-ILD (AUC = 0.833 ± 0.093, p < 0.001). Conclusions: These findings demonstrate the importance of clinical parameters in predicting treprostinil tolerance. Further investigation is warranted to refine the scoring system, particularly for PH-ILD patients.

Background: Intravascular lithotripsy (IVL) is approved for native coronary calcium modification, but data in saphenous vein grafts (SVGs) are scarce. Case Summary: An 87-year-old man with remote coronary artery bypass grafting presented with chest pain and was found to have non–ST-elevation myocardial infarction and new left ventricular dysfunction. Angiography revealed severe multivessel disease, with an 80% proximal lesion in a 30-year-old SVG collateralizing multiple territories with new wall motion abnormality. Percutaneous coronary intervention with embolic protection was attempted, but dense circumferential calcification limited balloon expansion. IVL with a 2.5 mm Shockwave balloon delivering 120 pulses allowed intravascular ultrasound passage, successful stent deployment, and satisfactory expansion. Discussion: This case demonstrates successful off-label IVL use in SVG PCI, adding to limited reports and highlighting its potential in challenging revascularization.

Elevated blood pressure (BP) affects up to 72% of hospitalized patients. Intravenous (IV) antihypertensives are indicated for hypertensive emergencies, but they are often given for asymptomatic BP elevations, leading to hypotension, acute kidney injury, and intensive care unit transfers without improving outcomes. At UConn John Dempsey Hospital, 69% of IV hydralazine use between June 2023 and January 2024 lacked appropriate indications. A redesigned order set required prescribers to select a guideline-supported indication before ordering hydralazine. The order also displayed the last 5 BPs and included hyperlinks to American Heart Association guidelines. Education sessions for residents and nurses reinforced best practices and provided alternatives for asymptomatic BP elevations. Nonindicated IV hydralazine use decreased from 69% to 25%. Order set modifications had a greater impact than education alone. Embedding decision support with targeted education offers a scalable, reproducible model for safer inpatient prescribing.