Parth Rali, MD

 increases the morbidity and mortality risk in interstitial lung disease (ILD), but evidence-based guidance for detecting PH, defined as a mean pulmonary arterial pressure (mPAP) > 20 mmHg, remains limited in this population.¹ The prospective PHINDER study put adults with ILD through routine noninvasive testing followed by right heart catheterization, with the goal of building an evidence-based PH screening tool.¹ An exploratory interim analysis presented at the 

 in Phoenix applied the validated PVD-B65 model, which predicts 1-year mortality, to 119 patients with PH.¹

The score assigns points for fibrotic ILD, BNP > 200 pg/mL, age > 65 years, pulmonary vascular resistance > 5 WU, and 6-minute walk distance < 150 m.¹,² Patients with mPAP of ≥ 25 mmHg had a numerically higher mean score than those with mPAP of 21 to 24 mmHg (5.3 ± 3.2 vs 4.2 ± 2.8), and fewer were low risk (38% vs 60%).¹ Idiopathic pulmonary fibrosis (IPF) had the highest mean score (7.9 ± 1.9), and no patients with IPF were low risk, versus 64% with hypersensitivity pneumonitis, 78% with connective tissue disease, and 80% with nonspecific interstitial pneumonia.¹

The investigators concluded the findings support earlier PH screening and timely hemodynamic assessment in patients with ILD, particularly those with IPF.¹ In the following Q&A, lead investigator Parth Rali, MD, professor of thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University, discusses why PH in ILD is so often detected late, how to interpret the IPF findings, and what the data should mean for screening and referral.

Q&A: Earlier Pulmonary Hypertension Screening in ILD

Why is PH in ILD so often caught late, and what is PHINDER trying to fix?

 Pulmonary hypertension in ILD is often caught late because there is no structured screening pathway for those patients. The traditional pathway we use for pulmonary hypertension screening, like echocardiogram and BNP markers, may not work perfectly well in patients with advanced interstitial lung disease.

A simple example I would give is that a lot of patients with interstitial lung disease may not get a good echocardiogram window, and a negative echocardiogram does not rule out pulmonary hypertension in this group. PHINDER is trying to fix that problem by identifying, and potentially developing, a risk score tool that can be used to identify patients with pulmonary hypertension and interstitial lung disease.

IPF had the highest risk scores, and no patients with IPF were low risk. How much reflects true risk versus how the score is built?

 I think what you are referring to is the PVD-B65 score, developed by Temple Lung Center physicians, as applied to the PHINDER cohort. I would like to explain that PVD-B65 was developed by a group of physicians from the Temple Lung Pulmonary Vascular Disease Department, where our sole interest was to identify patients with pulmonary hypertension related to ILD and predict their mortality.

The score was not only developed and published but also externally validated in the PVDOMICS cohort, and a manuscript is currently online in ERJ.

 In this manuscript, what we did is take the PVD-B65 score and apply it to the patients with ILD-PH in the PHINDER cohort. Not surprisingly, we noted that patients with IPF had a higher PVD-B65 score compared with other interstitial lung diseases.

So, this is the first cut at the data where we could not only diagnose patients with pulmonary hypertension but also stratify those patients in terms of 1-year mortality based on the PVD-B65 score. I’m hoping this is the beginning of the work, and we will continue to investigate further with evaluation of PFTs and chest CT scans to identify why the IPF cohort had higher PVD-B65 scores compared with other interstitial lung diseases.

Even mildly elevated pressures carried meaningful risk. What should that mean for screening and referral?

 Yes, any elevation of pulmonary hypertension in a patient with ILD carries significant mortality and morbidity risk for those patients. All of these patients with ILD-PH absolutely should be referred to the nearest lung transplant center.

Looking at the PHINDER cohort and our PVD-B65 application, I think it is up to clinicians not to settle on echocardiogram and clinical judgment alone to see who has PH versus who does not. Clinicians should refer the patient for right heart [catheterization] more aggressively, more effectively, and more rapidly. [That] way, if PH exists, [the] patient can either be treated with FDA-approved medications or be enrolled in clinical trials and simultaneously be referred for [a] lung transplant.

Rali P, Dersarkissian M, Gayen S, et al. Risk stratification in interstitial lung disease associated with pulmonary hypertension using the PVD-B65 model: interim analysis from the PHINDER study. Presented at: CHEST 2026 Annual Meeting; October 18-21, 2026; Phoenix, AZ. 

Gayen S, Pescatore J, Bittner M, et al. Development of the pulmonary fibrosis, pulmonary vascular resistance, six minute walk distance, B-type natriuretic peptide, age (PVD-B65) risk score for patients with chronic lung disease and pulmonary hypertension. 

Gayden S, Pescatore J, Illipparambil L, et al. The PVD-B65 risk score for interstitial lung disease and pulmonary hypertension: External validation using the PVDOMICS cohort. 

https://doi.org/10.1183/23120541.00307-2026

Articles

In PHINDER, IPF had the highest PVD-B65 mortality risk scores. Rali discusses why PH in ILD is missed and when to refer for right heart catheterization. 

Earlier PH Screening in ILD: PHINDER Data, With Parth Rali, MD 

The American Heart Association (AHA) and American College of Cardiology (ACC), with 8 partner societies, released their first joint guideline on acute 

 on February 19, 2026, in Circulation, spanning diagnosis through follow-up care.¹ The document replaces the low-, intermediate-, and high-risk framework with the AHA/ACC Acute PE Clinical Categories, ranging from category A (subclinical) to category E (cardiopulmonary failure).¹ Patients may shift between categories as they are reassessed, and the guideline gives a multidisciplinary pulmonary embolism response team (PERT) assessment a class 1 recommendation for categories C through E.¹

The guideline also provides direction on applying 7 validated PE-specific risk scores and names validation of the new clinical categories as a research priority.¹,² For clinicians accustomed to the European Society of Cardiology (ESC) framework, practical questions center on where the 2 systems diverge at the bedside, when to activate a PERT, and how to recognize normotensive shock before decompensation. Hospitals without an established PERT must also determine how to meet the new class 1 standard with the pulmonary, cardiology, radiology, and pharmacy specialists already on staff.

Parth Rali, MD, professor of thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University, directs the Temple University Health System PERT Program. Rali discussed the guideline’s changes, takeaways, and growing trial landscape as a panelist at the 

 in Phoenix, Arizona. In the following Q&A, Rali explains how the categories compare with ESC risk tiers, how to recognize normotensive shock, and how hospitals can build a PERT.

Q&A: Inside the New AHA/ACC Acute PE Categories

The guideline replaces low, intermediate, and high risk with categories A through E. What problem does this solve, and what is the biggest practice change?

The goal of the new guideline was to mimic the SCAI Shock Stage Classification that goes from A to E. By doing that, we are able to study several subphenotypes of intermediate-risk PE, which were classified as intermediate-high risk and then low risk [in the original classification].

With the new classification schema, we were able to subclassify that into several categories into C&D. We were also able to add the respiratory modifier, which is the biggest change, in my opinion, to the new guidelines given that it addresses respiratory decompensation into PE classification.

How does this classification compare with the ESC framework, and where might clinicians see real differences at the bedside?

 I would like to clarify that the ESC framework used by many clinicians is still very much validated. This new AHA classification adds an extra layer of filter in further subclassifying intermediate- and high-risk PE.

If physicians are more comfortable with the ESC classification, I think it is completely reasonable. As the PE response team gets involved, and once the PE response team is activated for the patient, it may be beneficial for expert PE members at local institutions to use the AHA classification to further stratify the patient. I do agree that the ESC classification is much easier to follow, particularly when it comes to PERT activation.

Category C seems to hold much of the uncertainty, including normotensive shock. How should clinicians recognize these patients before decompensation, and what should prompt escalation?

 I’d like to clarify that category C and category D truly represent the intermediate-risk PE from the previous classification. In the new AHA classification, subclinical shock, or normotensive shock, is labeled under category D, not category C.

The new classification gives several options to classify patients with normotensive shock. Some of them include shock index, rising lactic acid level, altered mental status, AKI, and the CPES score. This further classification will continue to evolve as we have more data coming in over the next few years.

For now, clinicians can use any of these parameters, which are easily available at the bedside, to identify the patient who may be at risk of normotensive shock. Identifying the patient in an emergency may help the team provide timely, effective, and expedited care for patients with pulmonary embolism.

The guideline gives PERT assessment a class 1 recommendation in categories C through E. How can hospitals without a formal PERT meet that standard?

 I completely agree that the guidelines give a class 1 recommendation for PERT for category C and above. The concept of the PERT is universally accepted. Who should form the PERT depends on local expertise and availability.

Each hospital has the capacity to form a PERT, and as I said, you need dedicated members who are involved in pulmonary embolism care. [That] can span from pulmonary critical care physicians to interventional cardiology, interventional radiology, hematology, vascular surgery, pharmacy, and other allied services.

Most of these subspecialties exist in some form at every single hospital. All we need is to bring this team together and form a multidisciplinary team. I think forming the multidisciplinary PE response team is the responsibility of not only physicians but also hospital administration, given that this is a class 1 recommendation.

Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. 

New pulmonary embolism guidelines highlight progress, encourage research, with Mark Creager, MD. HCPLive. Published February 25, 2026. Accessed October 27, 2026. 

https://www.hcplive.com/view/new-pulmonary-embolism-guidelines-highlight-progress-encourage-research-with-mark-creager-md

Parth Rali, MD, explains how the AHA/ACC A-through-E categories compare with ESC risk tiers and how hospitals can meet the class 1 PERT recommendation. 

Inside The New AHA/ACC Acute Pulmonary Embolism Categories 

Rali highlights a series of randomized, controlled trials that could reinvigorate the recently stagnant field of PE treatment development.

4 Trials That May Change Pulmonary Embolism, with Parth Rali, MD

It has been more than a decade since the PEITHO trial showed fibrinolytic therapy tenecteplase plus heparin more greatly prevented hemodynamic decompensation in patients with intermediate-risk 

. It was also that year, in 2014, when investigators investigators found standardized ultrasound-assisted catheter-directed thrombolysis (USAT) was superior to lone anticoagulation in reversal of right ventricular dilatation in patients with intermediate-risk PE.

In those 10 years, there has been a dearth of novel clinical trial insights into treating intermediate-risk PE, explained Parth Rali, MD. But that trend will quickly change.

American College of Chest Physicians (CHEST) 2025 Annual Meeting

 in Chicago, IL, Rali, director of the Temple University Health System Pulmonary Embolism Response Team (PERT) Program, reviewed a handful of randomized clinical trials rolling out data or just kicking off since 2024 that will likely influence PE intervention strategies.

“I think we are at the right time, for the right reasons, [to treat] our patients,” Rali said.

Here are 4 randomized, controlled trials Rali highlighted for their potential impact to PE intervention.

The study intends to enroll 650 patients with acute intermediate-high-risk PE, to assess reduced-dose intravenous tissue plasminogen activator (tPA) alteplase compared to standard anticoagulant therapy in all-cause death, hemodynamic decompensation, or PE recurrence ≤30 days post-randomization. Rali noted the trial has surpassed the mid-mark of enrollment.

“We are looking at a reduced dose, or a weight-based dose — which we have never studied in the PE space before,” Rali said. “I think that is exciting, because that’s more real-world, more evidence-based, and I think it’s going to decide which group of patients would benefit from tPA in the PE space.”

The multinational assessment aims to establish first-line treatment in patients with intermediate-high-risk PE and imminent hemodynamic collapse. Patients with confirmed acute PE, evidence of right ventricular dysfunction per imaging, a positive cardiac troponin test, and clinical criteria indicating elevated risk of early death or imminent hemodynamic collapise will be randomized 1:1 to either ultrasound-facilitated catheter-directed thrombolysis plus anticoagulants or lone anticoagulants.

Rali said updates from the trial assessing catheter-directed thrombectomy from a penumbra device versus anticoagulation in patients with PE will likely be presented at the Transcatheter Cardiovascular Therapeutics (TCT) Annual Symposium in late October.

Investigating large-bore thrombectomy versus anticoagulation in patients with intermediate-risk PE, this international trial plans to enroll ≤1200 patients across 100 sites — one of the largest randomized, controlled trials the field has seen, Rali said.

Rali additionally highlighted the PE-TRACT trial, an open-label investigation funded by the National Institutes of Health (NIH) assessing anticoagulation versus any form of catheter-directed therapy. The trial is unique two-fold: it is not industry0funded, and it will prioritize long-term, patient-reported outcomes similarly to immediate clinical outcomes.

“It’s kind of a nice balance of industry-funded and non-industry-funded trials looking at these similar populations and similar outcomes across US and European sites,” Rali said.

The output of data from these upcoming trials will practically triple the amount of interpretable patient outcomes for intermediate PE, Rali estimated — moving the observed population from approximately 1800 total randomized patients, to about 5300,

“We are looking at the randomized patients with intermediate-risk PE totaling around 5000 to 6000 in next couple of years, which I think is great for our patient care,” Rali said. “That means lot of work needs to be done toward how to interpret those trials, but I think it's exciting for the field.”

Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. 

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Kucher N, Boekstegers P, Müller OJ, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. 

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Sanchez O, Charles-Nelson A, Ageno W, et al. Reduced-Dose Intravenous Thrombolysis for Acute Intermediate-High-risk Pulmonary Embolism: Rationale and Design of the Pulmonary Embolism International THrOmbolysis (PEITHO)-3 trial. 

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Klok FA, Piazza G, Sharp ASP, et al. Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: Rationale and design of the HI-PEITHO study. 

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Rosovsky RP, Konstantinides SV, Moriarty JM, et al. A prospective, multicenter, randomized controlled trial evaluating anticoagulation alone vs anticoagulation plus computer assisted vacuum thrombectomy for the treatment of intermediate-high-risk acute pulmonary embolism: Rationale and design of the STORM-PE study. 

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Giri, Jay et al. PEERLESS II: A Randomized Controlled Trial of Large-Bore Thrombectomy Versus Anticoagulation in Intermediate-Risk Pulmonary Embolism. 

Journal of the Society for Cardiovascular Angiography & Interventions

Sista AK, Troxel AB, Tarpey T, et al. Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism. 

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