Key clinical point: Eptinezumab vs placebo demonstrated early, sustained, and clinically meaningful improvements in patient-reported outcomes in patients with chronic migraine and medication-overuse headache.

Major finding: Higher proportions of patients receiving 100/300 mg eptinezumab vs placebo showed ≥6-point reduction in the 6-item Headache Impact Test total score (46.0%/57.1% vs 31.7%) at week 4 and improvements in Patient Global Impression of Change scores (58.5%/67.4% vs 35.8%) and patient-identified most bothersome symptom (57.1%/64.6% vs 29.9%) at week 12, which was sustained until week 24.

Study details: This post hoc analysis of the phase 3 PROMISE-2 trial included a subgroup of 431 patients with chronic migraine and medication-overuse headache who were randomly assigned to receive ≤2 doses of eptinezumab (100/300 mg) or placebo.

Disclosures: The trial was funded by Lundbeck Seattle BioPharmaceuticals, Inc. Three authors declared being current or former employees of Lundbeck or its subsidiaries or a company contracted by H Lundbeck A/S. Several authors reported ties with various sources, including Lundbeck.

Source: Starling AJ et al. Eptinezumab improved patient-reported outcomes in patients with migraine and medication-overuse headache: Subgroup analysis of the randomized PROMISE-2 trial. Headache. 2023 (Jan 12). Doi: 10.1111/head.14434

Key clinical point: Eptinezumab vs placebo demonstrated early, sustained, and clinically meaningful improvements in patient-reported outcomes in patients with chronic migraine and medication-overuse headache.

Major finding: Higher proportions of patients receiving 100/300 mg eptinezumab vs placebo showed ≥6-point reduction in the 6-item Headache Impact Test total score (46.0%/57.1% vs 31.7%) at week 4 and improvements in Patient Global Impression of Change scores (58.5%/67.4% vs 35.8%) and patient-identified most bothersome symptom (57.1%/64.6% vs 29.9%) at week 12, which was sustained until week 24.

Study details: This post hoc analysis of the phase 3 PROMISE-2 trial included a subgroup of 431 patients with chronic migraine and medication-overuse headache who were randomly assigned to receive ≤2 doses of eptinezumab (100/300 mg) or placebo.

Disclosures: The trial was funded by Lundbeck Seattle BioPharmaceuticals, Inc. Three authors declared being current or former employees of Lundbeck or its subsidiaries or a company contracted by H Lundbeck A/S. Several authors reported ties with various sources, including Lundbeck.

Source: Starling AJ et al. Eptinezumab improved patient-reported outcomes in patients with migraine and medication-overuse headache: Subgroup analysis of the randomized PROMISE-2 trial. Headache. 2023 (Jan 12). Doi: 10.1111/head.14434

Key clinical point: Eptinezumab vs placebo demonstrated early, sustained, and clinically meaningful improvements in patient-reported outcomes in patients with chronic migraine and medication-overuse headache.

Major finding: Higher proportions of patients receiving 100/300 mg eptinezumab vs placebo showed ≥6-point reduction in the 6-item Headache Impact Test total score (46.0%/57.1% vs 31.7%) at week 4 and improvements in Patient Global Impression of Change scores (58.5%/67.4% vs 35.8%) and patient-identified most bothersome symptom (57.1%/64.6% vs 29.9%) at week 12, which was sustained until week 24.

Study details: This post hoc analysis of the phase 3 PROMISE-2 trial included a subgroup of 431 patients with chronic migraine and medication-overuse headache who were randomly assigned to receive ≤2 doses of eptinezumab (100/300 mg) or placebo.

Disclosures: The trial was funded by Lundbeck Seattle BioPharmaceuticals, Inc. Three authors declared being current or former employees of Lundbeck or its subsidiaries or a company contracted by H Lundbeck A/S. Several authors reported ties with various sources, including Lundbeck.

Source: Starling AJ et al. Eptinezumab improved patient-reported outcomes in patients with migraine and medication-overuse headache: Subgroup analysis of the randomized PROMISE-2 trial. Headache. 2023 (Jan 12). Doi: 10.1111/head.14434

Key clinical point: Galcanezumab significantly improved migraine-related outcomes in patients with high-frequency episodic migraine (HFEM) or chronic migraine, with a large proportion of patients experiencing improvements in photophobia mostly within the first month of treatment.

Major finding: Galcanezumab significantly improved headache days, migraine days, analgesics consumption, Migraine Disability Assessment scores, and Headache Impact Test-6 scores at 3 and 6 months (all P < .0001). Overall, 68.1% of patients experienced a significant improvement in ictal photophobia, of which 56.3% of patients reported an improvement within the first month of treatment.

Study details: This retrospective observational study included 47 patients with HFEM or chronic migraine and ≥3 previous prophylactic treatment failures who experienced moderate-to-severe photophobia during migraine attacks and received galcanezumab.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Schiano di Cola F et al. Photophobia and migraine outcome during treatment with galcanezumab. Front Neurol. 2023;13:1088036 (Jan 18). Doi: 10.3389/fneur.2022.1088036

Key clinical point: Galcanezumab significantly improved migraine-related outcomes in patients with high-frequency episodic migraine (HFEM) or chronic migraine, with a large proportion of patients experiencing improvements in photophobia mostly within the first month of treatment.

Major finding: Galcanezumab significantly improved headache days, migraine days, analgesics consumption, Migraine Disability Assessment scores, and Headache Impact Test-6 scores at 3 and 6 months (all P < .0001). Overall, 68.1% of patients experienced a significant improvement in ictal photophobia, of which 56.3% of patients reported an improvement within the first month of treatment.

Study details: This retrospective observational study included 47 patients with HFEM or chronic migraine and ≥3 previous prophylactic treatment failures who experienced moderate-to-severe photophobia during migraine attacks and received galcanezumab.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Schiano di Cola F et al. Photophobia and migraine outcome during treatment with galcanezumab. Front Neurol. 2023;13:1088036 (Jan 18). Doi: 10.3389/fneur.2022.1088036

Key clinical point: Galcanezumab significantly improved migraine-related outcomes in patients with high-frequency episodic migraine (HFEM) or chronic migraine, with a large proportion of patients experiencing improvements in photophobia mostly within the first month of treatment.

Major finding: Galcanezumab significantly improved headache days, migraine days, analgesics consumption, Migraine Disability Assessment scores, and Headache Impact Test-6 scores at 3 and 6 months (all P < .0001). Overall, 68.1% of patients experienced a significant improvement in ictal photophobia, of which 56.3% of patients reported an improvement within the first month of treatment.

Study details: This retrospective observational study included 47 patients with HFEM or chronic migraine and ≥3 previous prophylactic treatment failures who experienced moderate-to-severe photophobia during migraine attacks and received galcanezumab.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Schiano di Cola F et al. Photophobia and migraine outcome during treatment with galcanezumab. Front Neurol. 2023;13:1088036 (Jan 18). Doi: 10.3389/fneur.2022.1088036

Key clinical point: Rimegepant was effective for the acute treatment of migraine in patients who responded inadequately to 1 or ≥2 triptans and in current triptan users.

Major finding: Rimegepant was more effective than placebo at 2 hours postdose in providing freedom from pain and the most bothersome symptom (MBS) in patients with an inadequate response to 1 (both P < .001) and ≥2 (P  =  .013 and P < .001, respectively) triptans and in current triptan users (both P < .001). Among triptan-naive patients, rimegepant vs placebo significantly improved pain freedom (P  =  .007) but not MBS (P  =  .06).

Study details: This was a post hoc analysis of three phase 3 randomized controlled trials including 3507 patients with migraine who had (35.2%) or did not have (64.8%) inadequate response to triptans and who received rimegepant (n = 1749) or placebo (n = 1758).

Disclosures: This study was funded by Biohaven Pharmaceuticals, Inc. Six authors declared being employees of or holding stocks in Biohaven. Some authors declared ties with various sources.

Source: Lipton RB et al. Efficacy of rimegepant for the acute treatment of migraine based on triptan treatment experience: Pooled results from three phase 3 randomized clinical trials. Cephalalgia. 2023;43(2):3331024221141686 (Feb 5). Doi: 10.1177/03331024221141686

Key clinical point: Rimegepant was effective for the acute treatment of migraine in patients who responded inadequately to 1 or ≥2 triptans and in current triptan users.

Major finding: Rimegepant was more effective than placebo at 2 hours postdose in providing freedom from pain and the most bothersome symptom (MBS) in patients with an inadequate response to 1 (both P < .001) and ≥2 (P  =  .013 and P < .001, respectively) triptans and in current triptan users (both P < .001). Among triptan-naive patients, rimegepant vs placebo significantly improved pain freedom (P  =  .007) but not MBS (P  =  .06).

Study details: This was a post hoc analysis of three phase 3 randomized controlled trials including 3507 patients with migraine who had (35.2%) or did not have (64.8%) inadequate response to triptans and who received rimegepant (n = 1749) or placebo (n = 1758).

Disclosures: This study was funded by Biohaven Pharmaceuticals, Inc. Six authors declared being employees of or holding stocks in Biohaven. Some authors declared ties with various sources.

Source: Lipton RB et al. Efficacy of rimegepant for the acute treatment of migraine based on triptan treatment experience: Pooled results from three phase 3 randomized clinical trials. Cephalalgia. 2023;43(2):3331024221141686 (Feb 5). Doi: 10.1177/03331024221141686

Key clinical point: Rimegepant was effective for the acute treatment of migraine in patients who responded inadequately to 1 or ≥2 triptans and in current triptan users.

Major finding: Rimegepant was more effective than placebo at 2 hours postdose in providing freedom from pain and the most bothersome symptom (MBS) in patients with an inadequate response to 1 (both P < .001) and ≥2 (P  =  .013 and P < .001, respectively) triptans and in current triptan users (both P < .001). Among triptan-naive patients, rimegepant vs placebo significantly improved pain freedom (P  =  .007) but not MBS (P  =  .06).

Study details: This was a post hoc analysis of three phase 3 randomized controlled trials including 3507 patients with migraine who had (35.2%) or did not have (64.8%) inadequate response to triptans and who received rimegepant (n = 1749) or placebo (n = 1758).

Disclosures: This study was funded by Biohaven Pharmaceuticals, Inc. Six authors declared being employees of or holding stocks in Biohaven. Some authors declared ties with various sources.

Source: Lipton RB et al. Efficacy of rimegepant for the acute treatment of migraine based on triptan treatment experience: Pooled results from three phase 3 randomized clinical trials. Cephalalgia. 2023;43(2):3331024221141686 (Feb 5). Doi: 10.1177/03331024221141686

Key clinical point: A dose of 60 mg atogepant once daily was safe and well tolerated and demonstrated early efficacy sustained over 1 year in patients with episodic migraine.

Major finding: Treatment-emergent adverse events (TEAE), mostly mild or moderate, occurred in 67.0% vs 78.6% of patients receiving atogepant vs oral standard care, respectively. Serious TEAE occurred in 4.4% of atogepant-treated patients; however, treatment discontinuation due to adverse events (<6%) and lack of efficacy (<1%) was rare. Overall, 60.4% and 84.2% of patients reported ≥50% reduction in monthly migraine days during weeks 1-4 and 49-52 of atogepant treatment, respectively.

Study details: This open-label phase 3 trial included 744 patients with migraine with or without aura who were randomly assigned to receive 60 mg atogepant or oral standard care migraine preventive medication.

Disclosures: This study was sponsored by Allergan/AbbVie. Five authors declared being current or former employees of or holding stocks in AbbVie. Several authors declared serving as a consultants, speakers, scientific advisors,  or primary investigators for AbbVie and other sources.

Source: Ashina M et al. Once-daily oral atogepant for the long-term preventive treatment of migraine: Findings from a multicenter, randomized, open-label, phase 3 trial. Headache. 2023;63:79-88 (Jan 18). Doi: 10.1111/head.14439

Key clinical point: A dose of 60 mg atogepant once daily was safe and well tolerated and demonstrated early efficacy sustained over 1 year in patients with episodic migraine.

Major finding: Treatment-emergent adverse events (TEAE), mostly mild or moderate, occurred in 67.0% vs 78.6% of patients receiving atogepant vs oral standard care, respectively. Serious TEAE occurred in 4.4% of atogepant-treated patients; however, treatment discontinuation due to adverse events (<6%) and lack of efficacy (<1%) was rare. Overall, 60.4% and 84.2% of patients reported ≥50% reduction in monthly migraine days during weeks 1-4 and 49-52 of atogepant treatment, respectively.

Study details: This open-label phase 3 trial included 744 patients with migraine with or without aura who were randomly assigned to receive 60 mg atogepant or oral standard care migraine preventive medication.

Disclosures: This study was sponsored by Allergan/AbbVie. Five authors declared being current or former employees of or holding stocks in AbbVie. Several authors declared serving as a consultants, speakers, scientific advisors,  or primary investigators for AbbVie and other sources.

Source: Ashina M et al. Once-daily oral atogepant for the long-term preventive treatment of migraine: Findings from a multicenter, randomized, open-label, phase 3 trial. Headache. 2023;63:79-88 (Jan 18). Doi: 10.1111/head.14439

Key clinical point: A dose of 60 mg atogepant once daily was safe and well tolerated and demonstrated early efficacy sustained over 1 year in patients with episodic migraine.

Major finding: Treatment-emergent adverse events (TEAE), mostly mild or moderate, occurred in 67.0% vs 78.6% of patients receiving atogepant vs oral standard care, respectively. Serious TEAE occurred in 4.4% of atogepant-treated patients; however, treatment discontinuation due to adverse events (<6%) and lack of efficacy (<1%) was rare. Overall, 60.4% and 84.2% of patients reported ≥50% reduction in monthly migraine days during weeks 1-4 and 49-52 of atogepant treatment, respectively.

Study details: This open-label phase 3 trial included 744 patients with migraine with or without aura who were randomly assigned to receive 60 mg atogepant or oral standard care migraine preventive medication.

Disclosures: This study was sponsored by Allergan/AbbVie. Five authors declared being current or former employees of or holding stocks in AbbVie. Several authors declared serving as a consultants, speakers, scientific advisors,  or primary investigators for AbbVie and other sources.

Source: Ashina M et al. Once-daily oral atogepant for the long-term preventive treatment of migraine: Findings from a multicenter, randomized, open-label, phase 3 trial. Headache. 2023;63:79-88 (Jan 18). Doi: 10.1111/head.14439

Key clinical point: Prepregnancy migraine history was associated with a higher risk for adverse pregnancy outcomes, including preterm delivery, preeclampsia, and gestational hypertension.

Major finding: Participants with vs without a history of prepregnancy migraine were at a 17% increased risk for preterm delivery (adjusted relative risk [aRR] 1.17; 95% CI 1.05-1.30), 28% higher risk for gestational hypertension (aRR 1.28; 95% CI 1.11-1.48), and 40% greater risk for preeclampsia (aRR 1.40; 95% CI 1.19-1.65).

Study details: This prospective cohort study evaluated 30,555 incident pregnancies in 19,694 participants, of which 11.3% of participants reported a history of physician-diagnosed migraine with or without aura.

Disclosures: This study was supported by the US National Institutes of Health (NIH). Six authors declared receiving support from NIH unrelated to this study and reported ties with various sources.

Source: Purdue-Smithe AC et al. Prepregnancy migraine, migraine phenotype, and risk of adverse pregnancy outcomes. Neurology. 2023 (Jan 19). Doi: 10.1212/WNL.0000000000206831

Key clinical point: Prepregnancy migraine history was associated with a higher risk for adverse pregnancy outcomes, including preterm delivery, preeclampsia, and gestational hypertension.

Major finding: Participants with vs without a history of prepregnancy migraine were at a 17% increased risk for preterm delivery (adjusted relative risk [aRR] 1.17; 95% CI 1.05-1.30), 28% higher risk for gestational hypertension (aRR 1.28; 95% CI 1.11-1.48), and 40% greater risk for preeclampsia (aRR 1.40; 95% CI 1.19-1.65).

Study details: This prospective cohort study evaluated 30,555 incident pregnancies in 19,694 participants, of which 11.3% of participants reported a history of physician-diagnosed migraine with or without aura.

Disclosures: This study was supported by the US National Institutes of Health (NIH). Six authors declared receiving support from NIH unrelated to this study and reported ties with various sources.

Source: Purdue-Smithe AC et al. Prepregnancy migraine, migraine phenotype, and risk of adverse pregnancy outcomes. Neurology. 2023 (Jan 19). Doi: 10.1212/WNL.0000000000206831

Key clinical point: Prepregnancy migraine history was associated with a higher risk for adverse pregnancy outcomes, including preterm delivery, preeclampsia, and gestational hypertension.

Major finding: Participants with vs without a history of prepregnancy migraine were at a 17% increased risk for preterm delivery (adjusted relative risk [aRR] 1.17; 95% CI 1.05-1.30), 28% higher risk for gestational hypertension (aRR 1.28; 95% CI 1.11-1.48), and 40% greater risk for preeclampsia (aRR 1.40; 95% CI 1.19-1.65).

Study details: This prospective cohort study evaluated 30,555 incident pregnancies in 19,694 participants, of which 11.3% of participants reported a history of physician-diagnosed migraine with or without aura.

Disclosures: This study was supported by the US National Institutes of Health (NIH). Six authors declared receiving support from NIH unrelated to this study and reported ties with various sources.

Source: Purdue-Smithe AC et al. Prepregnancy migraine, migraine phenotype, and risk of adverse pregnancy outcomes. Neurology. 2023 (Jan 19). Doi: 10.1212/WNL.0000000000206831

Key clinical point: Use of remote electrical neuromodulation (REN) every other day is a safe and effective preventive treatment for migraine.

Major finding: REN was superior to placebo in reducing the mean number of migraine days per month (P < .001), moderate or severe headache days per month (P = .005), percentage of patients achieving ≥50% reduction in headache days (P = .015), and days of acute medication intake (P = .001). No device-related serious adverse events were reported in either REN or placebo group.

Study details: Findings are from a prospective, randomized, double-blind trial including 179 patients with migraine who were randomly assigned to receive REN (n = 95) or placebo stimulation (n = 84) every other day.

Disclosures: This study was funded by Theranica Bio-Electronics. Some authors declared receiving research, support, or educational grants, royalties, or honoraria from or serving as a consultant, on a speaker bureau, or on an advisory board for various sources, including Theranica.

Source: Tepper SJ et al. Remote electrical neuromodulation for migraine prevention: A double-blind, randomized, placebo-controlled clinical trial. Headache. 2023 (Jan 27). Doi: 10.1111/head.14469

Key clinical point: Use of remote electrical neuromodulation (REN) every other day is a safe and effective preventive treatment for migraine.

Major finding: REN was superior to placebo in reducing the mean number of migraine days per month (P < .001), moderate or severe headache days per month (P = .005), percentage of patients achieving ≥50% reduction in headache days (P = .015), and days of acute medication intake (P = .001). No device-related serious adverse events were reported in either REN or placebo group.

Study details: Findings are from a prospective, randomized, double-blind trial including 179 patients with migraine who were randomly assigned to receive REN (n = 95) or placebo stimulation (n = 84) every other day.

Disclosures: This study was funded by Theranica Bio-Electronics. Some authors declared receiving research, support, or educational grants, royalties, or honoraria from or serving as a consultant, on a speaker bureau, or on an advisory board for various sources, including Theranica.

Source: Tepper SJ et al. Remote electrical neuromodulation for migraine prevention: A double-blind, randomized, placebo-controlled clinical trial. Headache. 2023 (Jan 27). Doi: 10.1111/head.14469

Key clinical point: Use of remote electrical neuromodulation (REN) every other day is a safe and effective preventive treatment for migraine.

Major finding: REN was superior to placebo in reducing the mean number of migraine days per month (P < .001), moderate or severe headache days per month (P = .005), percentage of patients achieving ≥50% reduction in headache days (P = .015), and days of acute medication intake (P = .001). No device-related serious adverse events were reported in either REN or placebo group.

Study details: Findings are from a prospective, randomized, double-blind trial including 179 patients with migraine who were randomly assigned to receive REN (n = 95) or placebo stimulation (n = 84) every other day.

Disclosures: This study was funded by Theranica Bio-Electronics. Some authors declared receiving research, support, or educational grants, royalties, or honoraria from or serving as a consultant, on a speaker bureau, or on an advisory board for various sources, including Theranica.

Source: Tepper SJ et al. Remote electrical neuromodulation for migraine prevention: A double-blind, randomized, placebo-controlled clinical trial. Headache. 2023 (Jan 27). Doi: 10.1111/head.14469

A jump in natriuretic peptide levels over several years in middle-aged adults points to worsened long-term risks for incident heart failure (HF) and death. But their predicted long-term survival improves if serial testing shows a drop in those levels, suggests a new analysis based on a well-known longitudinal study cohort.

The findings support the risk-stratification potential of serial natriuretic peptide testing, which may improve on individual assays for predicting future HF. Such serial assays might also be useful for guiding therapy aimed at preventing, for example, progression to clinical HF, researchers speculate on the basis of the current study,

The analysis of almost 1,000 members of the ARIC (Atherosclerosis Risk in Community) cohort had been free of clinical HF at the first of two NT-proBNP assays, which were performed 6 years apart. Their 20-year clinical risk was linked to the trajectory of NT-proBNP levels across the two earlier assays.

For example, adjusted risk of incident HF more than doubled for participants with NT-proBNP levels exceeding 125 pg/mL on both assays, compared with levels that stayed under the cut point at both assays. Their mortality risk climbed by about two-thirds.

Risk for incident HF and of death climbed 86% and 32%, respectively, if NT-proBNP levels rose over the 6 years from less than to greater than 125 pg/mL. But long-term survival improved if serial assays showed a drop from the higher to the lower level.

Rising NT-proBNP levels over several years probably reflect ongoing exposure to risk factors such as hypertension or diabetes. Conversely, decreasing NT-proBNP levels likely reflect some success at keeping such risk factors under control, propose the authors of the analysis published in JAMA Cardiology. The study was led by Xiaoming Jia, MD, Baylor College of Medicine, Houston.

The findings raise the possibility that reducing NT-proBNP levels through risk-factor modification, tracked by serial assays, may potentially improve long-term risk for death or incident HF.

Such therapy, guided by natriuretic peptides, might prove especially useful in asymptomatic adults with modifiable HF risk factors but without known NT-proBNP elevation or cardiac structural changes, so-called stage A HF, senior author Vijay Nambi, MD, PhD, also of Baylor, observed for this news organization.

The best populations for serial NT-proBNP assays to guide therapy, Dr. Nambi said, should become clear “as more data emerges.” But the threshold for ordering such tests would probably be lower for people in stage A whose rising NT-proBNP levels later reclassify them as stage B, also called pre-HF.

In such cases, he speculated, intensified therapy of HF risk factors such as uncontrolled hypertension or diabetes – prompted by greater NT-proBNP levels at serial testing – might possibly avert progression to clinical HF.

Mitchel L. Zoler/MDedge News

“These investigators have nicely demonstrated that one measurement of the biomarker may not be sufficient, that maybe it undercaptures the true burden of people who eventually will develop heart failure,” Muthiah Vaduganathan, MD, MPH, told this news organization.

The study raises the possibility “that the serial natriuretic peptide strategy may be more efficient and more comprehensive in identifying those who will eventually progress,” said Dr. Vaduganathan, of Brigham and Women’s Hospital and Harvard Medical School, Boston, who was not associated with the ARIC analysis.

An open question, he added, is whether the predicted risk is modifiable. “If you are able to provide the biomarker information to treating clinicians, can they do something to attenuate the risk?”

The outlook is hopeful, given contemporary therapies “that can slow and even prevent heart failure in at-risk populations,” Dr. Vaduganathan said. For example, “The selective allocation of SGLT2 inhibitors to those with elevated natriuretic peptide levels, perhaps as captured in serial measurements, would be of great interest.”

The analysis included 9,776 adults (56.5% women, 21.3% Black) without HF who underwent NT-proBNP testing at the second and – about 6 years later – the fourth scheduled clinical visits in the ARIC study, which had enrolled persons aged 45-64 from four diverse communities from across the United States.

Adjusted hazard ratios for incident HF according to NT-proBNP changes from the first to second assays relative to 125 pg/mL were as follows:

• 1.86 (95% confidence interval, 1.60-2.16) when levels rose to higher than the cut point.
• 2.40 (95% CI, 2.00-2.88) when both levels exceeded the cut point.

The corresponding adjusted HRs for death from any cause were as follows:

• 1.32 (95%CI, 1.19-1.47) when levels rose to higher than 125 mg/mL.
• 1.68 (95% CI, 1.47-1.91) when both levels were above the cut point.

The risks for incident HF and for death rose significantly by 6% and 5%, respectively, per standard deviation NT-proBNP increase from the first to second assay.

Risks for HF and mortality for participants whose NT-proBNP levels declined from greater than to less than 125 pg/mL were similar to those whose levels remained low at both assays.

Cost-effectiveness would be another issue when implementing a strategy that calls for multiple biomarker assays, Dr. Vaduganathan observed.

“Surely, we would want to demonstrate that the laboratory measurement costs are offset by downstream prevention of heart failure events that could be averted by use of effective medical therapy, such SGLT2 inhibitors.”

ARIC has been funded by the National Institutes of Health and Department of Health and Human Services. Dr. Nambi discloses receiving grants from the National Institutes of Health during the conduct of the study; support from Amgen; and stocks from Abbott Laboratories. Disclosures for the other authors are in the report. Dr. Vaduganathan has disclosed receiving grants or serving on advisory boards for American Regent, Amgen, AstraZeneca, Bayer AG, Baxter Healthcare, Boehringer Ingelheim, Cytokinetics, Lexicon Pharmaceuticals, Novartis, Pharmacosmos, Relypsa, Roche Diagnostics, Sanofi, and Tricog Health; speaking for AstraZeneca, Novartis, and Roche Diagnostics; and serving on trial committees for studies sponsored by Galmed, Novartis, Bayer AG, Occlutech, and Impulse Dynamics.

A version of this article originally appeared on Medscape.com.

A jump in natriuretic peptide levels over several years in middle-aged adults points to worsened long-term risks for incident heart failure (HF) and death. But their predicted long-term survival improves if serial testing shows a drop in those levels, suggests a new analysis based on a well-known longitudinal study cohort.

The findings support the risk-stratification potential of serial natriuretic peptide testing, which may improve on individual assays for predicting future HF. Such serial assays might also be useful for guiding therapy aimed at preventing, for example, progression to clinical HF, researchers speculate on the basis of the current study,

The analysis of almost 1,000 members of the ARIC (Atherosclerosis Risk in Community) cohort had been free of clinical HF at the first of two NT-proBNP assays, which were performed 6 years apart. Their 20-year clinical risk was linked to the trajectory of NT-proBNP levels across the two earlier assays.

For example, adjusted risk of incident HF more than doubled for participants with NT-proBNP levels exceeding 125 pg/mL on both assays, compared with levels that stayed under the cut point at both assays. Their mortality risk climbed by about two-thirds.

Risk for incident HF and of death climbed 86% and 32%, respectively, if NT-proBNP levels rose over the 6 years from less than to greater than 125 pg/mL. But long-term survival improved if serial assays showed a drop from the higher to the lower level.

Rising NT-proBNP levels over several years probably reflect ongoing exposure to risk factors such as hypertension or diabetes. Conversely, decreasing NT-proBNP levels likely reflect some success at keeping such risk factors under control, propose the authors of the analysis published in JAMA Cardiology. The study was led by Xiaoming Jia, MD, Baylor College of Medicine, Houston.

The findings raise the possibility that reducing NT-proBNP levels through risk-factor modification, tracked by serial assays, may potentially improve long-term risk for death or incident HF.

Such therapy, guided by natriuretic peptides, might prove especially useful in asymptomatic adults with modifiable HF risk factors but without known NT-proBNP elevation or cardiac structural changes, so-called stage A HF, senior author Vijay Nambi, MD, PhD, also of Baylor, observed for this news organization.

The best populations for serial NT-proBNP assays to guide therapy, Dr. Nambi said, should become clear “as more data emerges.” But the threshold for ordering such tests would probably be lower for people in stage A whose rising NT-proBNP levels later reclassify them as stage B, also called pre-HF.

In such cases, he speculated, intensified therapy of HF risk factors such as uncontrolled hypertension or diabetes – prompted by greater NT-proBNP levels at serial testing – might possibly avert progression to clinical HF.

Mitchel L. Zoler/MDedge News

“These investigators have nicely demonstrated that one measurement of the biomarker may not be sufficient, that maybe it undercaptures the true burden of people who eventually will develop heart failure,” Muthiah Vaduganathan, MD, MPH, told this news organization.

The study raises the possibility “that the serial natriuretic peptide strategy may be more efficient and more comprehensive in identifying those who will eventually progress,” said Dr. Vaduganathan, of Brigham and Women’s Hospital and Harvard Medical School, Boston, who was not associated with the ARIC analysis.

An open question, he added, is whether the predicted risk is modifiable. “If you are able to provide the biomarker information to treating clinicians, can they do something to attenuate the risk?”

The outlook is hopeful, given contemporary therapies “that can slow and even prevent heart failure in at-risk populations,” Dr. Vaduganathan said. For example, “The selective allocation of SGLT2 inhibitors to those with elevated natriuretic peptide levels, perhaps as captured in serial measurements, would be of great interest.”

The analysis included 9,776 adults (56.5% women, 21.3% Black) without HF who underwent NT-proBNP testing at the second and – about 6 years later – the fourth scheduled clinical visits in the ARIC study, which had enrolled persons aged 45-64 from four diverse communities from across the United States.

Adjusted hazard ratios for incident HF according to NT-proBNP changes from the first to second assays relative to 125 pg/mL were as follows:

• 1.86 (95% confidence interval, 1.60-2.16) when levels rose to higher than the cut point.
• 2.40 (95% CI, 2.00-2.88) when both levels exceeded the cut point.

The corresponding adjusted HRs for death from any cause were as follows:

• 1.32 (95%CI, 1.19-1.47) when levels rose to higher than 125 mg/mL.
• 1.68 (95% CI, 1.47-1.91) when both levels were above the cut point.

The risks for incident HF and for death rose significantly by 6% and 5%, respectively, per standard deviation NT-proBNP increase from the first to second assay.

Risks for HF and mortality for participants whose NT-proBNP levels declined from greater than to less than 125 pg/mL were similar to those whose levels remained low at both assays.

Cost-effectiveness would be another issue when implementing a strategy that calls for multiple biomarker assays, Dr. Vaduganathan observed.

“Surely, we would want to demonstrate that the laboratory measurement costs are offset by downstream prevention of heart failure events that could be averted by use of effective medical therapy, such SGLT2 inhibitors.”

ARIC has been funded by the National Institutes of Health and Department of Health and Human Services. Dr. Nambi discloses receiving grants from the National Institutes of Health during the conduct of the study; support from Amgen; and stocks from Abbott Laboratories. Disclosures for the other authors are in the report. Dr. Vaduganathan has disclosed receiving grants or serving on advisory boards for American Regent, Amgen, AstraZeneca, Bayer AG, Baxter Healthcare, Boehringer Ingelheim, Cytokinetics, Lexicon Pharmaceuticals, Novartis, Pharmacosmos, Relypsa, Roche Diagnostics, Sanofi, and Tricog Health; speaking for AstraZeneca, Novartis, and Roche Diagnostics; and serving on trial committees for studies sponsored by Galmed, Novartis, Bayer AG, Occlutech, and Impulse Dynamics.

A version of this article originally appeared on Medscape.com.

A jump in natriuretic peptide levels over several years in middle-aged adults points to worsened long-term risks for incident heart failure (HF) and death. But their predicted long-term survival improves if serial testing shows a drop in those levels, suggests a new analysis based on a well-known longitudinal study cohort.

The findings support the risk-stratification potential of serial natriuretic peptide testing, which may improve on individual assays for predicting future HF. Such serial assays might also be useful for guiding therapy aimed at preventing, for example, progression to clinical HF, researchers speculate on the basis of the current study,

The analysis of almost 1,000 members of the ARIC (Atherosclerosis Risk in Community) cohort had been free of clinical HF at the first of two NT-proBNP assays, which were performed 6 years apart. Their 20-year clinical risk was linked to the trajectory of NT-proBNP levels across the two earlier assays.

For example, adjusted risk of incident HF more than doubled for participants with NT-proBNP levels exceeding 125 pg/mL on both assays, compared with levels that stayed under the cut point at both assays. Their mortality risk climbed by about two-thirds.

Risk for incident HF and of death climbed 86% and 32%, respectively, if NT-proBNP levels rose over the 6 years from less than to greater than 125 pg/mL. But long-term survival improved if serial assays showed a drop from the higher to the lower level.

Rising NT-proBNP levels over several years probably reflect ongoing exposure to risk factors such as hypertension or diabetes. Conversely, decreasing NT-proBNP levels likely reflect some success at keeping such risk factors under control, propose the authors of the analysis published in JAMA Cardiology. The study was led by Xiaoming Jia, MD, Baylor College of Medicine, Houston.

The findings raise the possibility that reducing NT-proBNP levels through risk-factor modification, tracked by serial assays, may potentially improve long-term risk for death or incident HF.

Such therapy, guided by natriuretic peptides, might prove especially useful in asymptomatic adults with modifiable HF risk factors but without known NT-proBNP elevation or cardiac structural changes, so-called stage A HF, senior author Vijay Nambi, MD, PhD, also of Baylor, observed for this news organization.

The best populations for serial NT-proBNP assays to guide therapy, Dr. Nambi said, should become clear “as more data emerges.” But the threshold for ordering such tests would probably be lower for people in stage A whose rising NT-proBNP levels later reclassify them as stage B, also called pre-HF.

In such cases, he speculated, intensified therapy of HF risk factors such as uncontrolled hypertension or diabetes – prompted by greater NT-proBNP levels at serial testing – might possibly avert progression to clinical HF.

Mitchel L. Zoler/MDedge News

“These investigators have nicely demonstrated that one measurement of the biomarker may not be sufficient, that maybe it undercaptures the true burden of people who eventually will develop heart failure,” Muthiah Vaduganathan, MD, MPH, told this news organization.

The study raises the possibility “that the serial natriuretic peptide strategy may be more efficient and more comprehensive in identifying those who will eventually progress,” said Dr. Vaduganathan, of Brigham and Women’s Hospital and Harvard Medical School, Boston, who was not associated with the ARIC analysis.

An open question, he added, is whether the predicted risk is modifiable. “If you are able to provide the biomarker information to treating clinicians, can they do something to attenuate the risk?”

The outlook is hopeful, given contemporary therapies “that can slow and even prevent heart failure in at-risk populations,” Dr. Vaduganathan said. For example, “The selective allocation of SGLT2 inhibitors to those with elevated natriuretic peptide levels, perhaps as captured in serial measurements, would be of great interest.”

The analysis included 9,776 adults (56.5% women, 21.3% Black) without HF who underwent NT-proBNP testing at the second and – about 6 years later – the fourth scheduled clinical visits in the ARIC study, which had enrolled persons aged 45-64 from four diverse communities from across the United States.

Adjusted hazard ratios for incident HF according to NT-proBNP changes from the first to second assays relative to 125 pg/mL were as follows:

• 1.86 (95% confidence interval, 1.60-2.16) when levels rose to higher than the cut point.
• 2.40 (95% CI, 2.00-2.88) when both levels exceeded the cut point.

The corresponding adjusted HRs for death from any cause were as follows:

• 1.32 (95%CI, 1.19-1.47) when levels rose to higher than 125 mg/mL.
• 1.68 (95% CI, 1.47-1.91) when both levels were above the cut point.

The risks for incident HF and for death rose significantly by 6% and 5%, respectively, per standard deviation NT-proBNP increase from the first to second assay.

Risks for HF and mortality for participants whose NT-proBNP levels declined from greater than to less than 125 pg/mL were similar to those whose levels remained low at both assays.

Cost-effectiveness would be another issue when implementing a strategy that calls for multiple biomarker assays, Dr. Vaduganathan observed.

“Surely, we would want to demonstrate that the laboratory measurement costs are offset by downstream prevention of heart failure events that could be averted by use of effective medical therapy, such SGLT2 inhibitors.”

ARIC has been funded by the National Institutes of Health and Department of Health and Human Services. Dr. Nambi discloses receiving grants from the National Institutes of Health during the conduct of the study; support from Amgen; and stocks from Abbott Laboratories. Disclosures for the other authors are in the report. Dr. Vaduganathan has disclosed receiving grants or serving on advisory boards for American Regent, Amgen, AstraZeneca, Bayer AG, Baxter Healthcare, Boehringer Ingelheim, Cytokinetics, Lexicon Pharmaceuticals, Novartis, Pharmacosmos, Relypsa, Roche Diagnostics, Sanofi, and Tricog Health; speaking for AstraZeneca, Novartis, and Roche Diagnostics; and serving on trial committees for studies sponsored by Galmed, Novartis, Bayer AG, Occlutech, and Impulse Dynamics.

A version of this article originally appeared on Medscape.com.

Hospitalized COVID-19 patients with high troponin levels are twice as likely to have cardiac abnormalities than those with normal troponin, with or without COVID-19, a multicenter U.K. study suggests.

The causes were diverse, myocarditis prevalence was lower than previously reported, and myocardial scar emerged as an independent risk factor for adverse cardiovascular outcomes at 12 months.

“We know that multiorgan involvement in hospitalized patients with COVID-19 is common ... and may result in acute myocardial injury, detected by an increase in cardiac troponin concentrations,” John P. Greenwood, PhD, of the University of Leeds (England), told this news organization. “Elevated cardiac troponin is associated with a worse prognosis.”

“Multiple mechanisms of myocardial injury have been proposed and ... mitigation or prevention strategies likely depend on the underpinning mechanisms,” he said. “The sequelae of scar may predispose to late events.”

The study, published online  in Circulation, also identified a new pattern of microinfarction on cardiac magnetic resonance (CMR) imaging, highlighting the pro-thrombotic nature of SARS-CoV-2, Dr. Greenwood said.
 

Injury patterns different

Three hundred and forty-two patients with COVID-19 and elevated troponin levels (COVID+/troponin+) across 25 centers were enrolled between June 2020 and March 2021 in COVID-HEART, deemed an “urgent public health study” in the United Kingdom. The aim was to characterize myocardial injury and its associations and sequelae in convalescent patients after hospitalization with COVID-19.

Enrollment took place during the Wuhan and Alpha waves of COVID-19: before vaccination and when dexamethasone and anticoagulant protocols were emerging. All participants underwent CMR at a median of 21 days after discharge.

Two prospective control groups also were recruited: 64 patients with COVID-19 and normal troponin levels (COVID+/troponin−) and 113 without COVID-19 or elevated troponin matched by age and cardiovascular comorbidities (COVID−/comorbidity+).

Overall, participants’ median age was 61 years and 69% were men. Common comorbidities included hypertension (47%), obesity (43%), and diabetes (25%).

The frequency of any heart abnormality – for example, left or right ventricular impairment, scar, or pericardial disease – was twice as great (61%) in COVID+/troponin+ cases, compared with controls (36% for COVID+/troponin− patients versus 31% for COVID−/comorbidity+ patients).

Specifically, more cases than controls had ventricular impairment (17.2% vs. 3.1% and 7.1%) or scar (42% vs. 7% and 23%).

The myocardial injury pattern differed between cases and controls, with cases more likely to have infarction (13% vs. 2% and 7%) or microinfarction (9% vs. 0% and 1%).

However, there was no between-group difference in nonischemic scar (13% vs. 5% and 14%).

The prevalence of probable recent myocarditis was 6.7% in cases, compared with 1.7% in controls without COVID-19 – “much lower” than in previous studies, Dr. Greenwood noted.

During follow-up, four COVID+/troponin+ patients (1.2%) died, and 34 (10%) experienced a subsequent major adverse cardiovascular event (MACE; 10.2%), which was similar to controls (6.1%).

Myocardial scar, but not previous COVID-19 infection or troponin level, was an independent predictor of MACE (odds ratio, 2.25).

“These findings suggest that macroangiopathic and microangiopathic thrombosis may be the key pathologic process for myocardial injury in COVID-19 survivors,” the authors conclude.

Dr. Greenwood added, “We are currently analyzing the 6-month follow-up CMR scans, the quality-of-life questionnaires, and the 6-minute walk tests. These will give us great understanding of how the heart repairs after acute myocardial injury associated with COVID-19. It will also allow us to assess the impact on patient quality of life and functional capacity.”
 

‘Tour de force’

James A. de Lemos, MD, co-chair of the American Heart Association’s COVID-19 CVD Registry Steering Committee and a professor of medicine at the University of Texas Southwestern Medical Center, Dallas, said, “This is a tour de force collaboration – obtaining this many MRIs across multiple centers in the pandemic is quite remarkable. The study highlights the multiple different processes that lead to cardiac injury in COVID patients, complements autopsy studies and prior smaller MRI studies, [and] also provides the best data on the rate of myocarditis to date among the subset of COVID patients with cardiac injury.”

Overall, he said, the findings “do support closer follow-up for patients who had COVID and elevated troponins. We need to see follow-up MRI results in this cohort, as well as longer term outcomes. We also need studies on newer, more benign variants that are likely to have lower rates of cardiac injury and even fewer MRI abnormalities.”

Matthias Stuber, PhD, and Aaron L. Baggish, MD, both of Lausanne University Hospital and University of Lausanne, Switzerland, noted in a related editorial, “We are also reminded that the clinical severity of COVID-19 is most often dictated by the presence of pre-existing comorbidity, with antecedent ischemic scar now added to the long list of bad actors. Although not the primary focus of the COVID-HEART study, the question of whether cardiac troponin levels should be checked routinely and universally during the index admission for COVID-19 remains unresolved,” they noted.

“In general, we are most effective as clinicians when we use tests to confirm or rule out the specific disease processes suspected by careful basic clinical assessment rather than in a shotgun manner among undifferentiated all-comers,” they conclude.

No commercial funding or relevant financial relationships were reported.

A version of this article originally appeared on Medscape.com.

Hospitalized COVID-19 patients with high troponin levels are twice as likely to have cardiac abnormalities than those with normal troponin, with or without COVID-19, a multicenter U.K. study suggests.

The causes were diverse, myocarditis prevalence was lower than previously reported, and myocardial scar emerged as an independent risk factor for adverse cardiovascular outcomes at 12 months.

“We know that multiorgan involvement in hospitalized patients with COVID-19 is common ... and may result in acute myocardial injury, detected by an increase in cardiac troponin concentrations,” John P. Greenwood, PhD, of the University of Leeds (England), told this news organization. “Elevated cardiac troponin is associated with a worse prognosis.”

“Multiple mechanisms of myocardial injury have been proposed and ... mitigation or prevention strategies likely depend on the underpinning mechanisms,” he said. “The sequelae of scar may predispose to late events.”

The study, published online  in Circulation, also identified a new pattern of microinfarction on cardiac magnetic resonance (CMR) imaging, highlighting the pro-thrombotic nature of SARS-CoV-2, Dr. Greenwood said.
 

Injury patterns different

Three hundred and forty-two patients with COVID-19 and elevated troponin levels (COVID+/troponin+) across 25 centers were enrolled between June 2020 and March 2021 in COVID-HEART, deemed an “urgent public health study” in the United Kingdom. The aim was to characterize myocardial injury and its associations and sequelae in convalescent patients after hospitalization with COVID-19.

Enrollment took place during the Wuhan and Alpha waves of COVID-19: before vaccination and when dexamethasone and anticoagulant protocols were emerging. All participants underwent CMR at a median of 21 days after discharge.

Two prospective control groups also were recruited: 64 patients with COVID-19 and normal troponin levels (COVID+/troponin−) and 113 without COVID-19 or elevated troponin matched by age and cardiovascular comorbidities (COVID−/comorbidity+).

Overall, participants’ median age was 61 years and 69% were men. Common comorbidities included hypertension (47%), obesity (43%), and diabetes (25%).

The frequency of any heart abnormality – for example, left or right ventricular impairment, scar, or pericardial disease – was twice as great (61%) in COVID+/troponin+ cases, compared with controls (36% for COVID+/troponin− patients versus 31% for COVID−/comorbidity+ patients).

Specifically, more cases than controls had ventricular impairment (17.2% vs. 3.1% and 7.1%) or scar (42% vs. 7% and 23%).

The myocardial injury pattern differed between cases and controls, with cases more likely to have infarction (13% vs. 2% and 7%) or microinfarction (9% vs. 0% and 1%).

However, there was no between-group difference in nonischemic scar (13% vs. 5% and 14%).

The prevalence of probable recent myocarditis was 6.7% in cases, compared with 1.7% in controls without COVID-19 – “much lower” than in previous studies, Dr. Greenwood noted.

During follow-up, four COVID+/troponin+ patients (1.2%) died, and 34 (10%) experienced a subsequent major adverse cardiovascular event (MACE; 10.2%), which was similar to controls (6.1%).

Myocardial scar, but not previous COVID-19 infection or troponin level, was an independent predictor of MACE (odds ratio, 2.25).

“These findings suggest that macroangiopathic and microangiopathic thrombosis may be the key pathologic process for myocardial injury in COVID-19 survivors,” the authors conclude.

Dr. Greenwood added, “We are currently analyzing the 6-month follow-up CMR scans, the quality-of-life questionnaires, and the 6-minute walk tests. These will give us great understanding of how the heart repairs after acute myocardial injury associated with COVID-19. It will also allow us to assess the impact on patient quality of life and functional capacity.”
 

‘Tour de force’

James A. de Lemos, MD, co-chair of the American Heart Association’s COVID-19 CVD Registry Steering Committee and a professor of medicine at the University of Texas Southwestern Medical Center, Dallas, said, “This is a tour de force collaboration – obtaining this many MRIs across multiple centers in the pandemic is quite remarkable. The study highlights the multiple different processes that lead to cardiac injury in COVID patients, complements autopsy studies and prior smaller MRI studies, [and] also provides the best data on the rate of myocarditis to date among the subset of COVID patients with cardiac injury.”

Overall, he said, the findings “do support closer follow-up for patients who had COVID and elevated troponins. We need to see follow-up MRI results in this cohort, as well as longer term outcomes. We also need studies on newer, more benign variants that are likely to have lower rates of cardiac injury and even fewer MRI abnormalities.”

Matthias Stuber, PhD, and Aaron L. Baggish, MD, both of Lausanne University Hospital and University of Lausanne, Switzerland, noted in a related editorial, “We are also reminded that the clinical severity of COVID-19 is most often dictated by the presence of pre-existing comorbidity, with antecedent ischemic scar now added to the long list of bad actors. Although not the primary focus of the COVID-HEART study, the question of whether cardiac troponin levels should be checked routinely and universally during the index admission for COVID-19 remains unresolved,” they noted.

“In general, we are most effective as clinicians when we use tests to confirm or rule out the specific disease processes suspected by careful basic clinical assessment rather than in a shotgun manner among undifferentiated all-comers,” they conclude.

No commercial funding or relevant financial relationships were reported.

A version of this article originally appeared on Medscape.com.

Hospitalized COVID-19 patients with high troponin levels are twice as likely to have cardiac abnormalities than those with normal troponin, with or without COVID-19, a multicenter U.K. study suggests.

The causes were diverse, myocarditis prevalence was lower than previously reported, and myocardial scar emerged as an independent risk factor for adverse cardiovascular outcomes at 12 months.

“We know that multiorgan involvement in hospitalized patients with COVID-19 is common ... and may result in acute myocardial injury, detected by an increase in cardiac troponin concentrations,” John P. Greenwood, PhD, of the University of Leeds (England), told this news organization. “Elevated cardiac troponin is associated with a worse prognosis.”

“Multiple mechanisms of myocardial injury have been proposed and ... mitigation or prevention strategies likely depend on the underpinning mechanisms,” he said. “The sequelae of scar may predispose to late events.”

The study, published online  in Circulation, also identified a new pattern of microinfarction on cardiac magnetic resonance (CMR) imaging, highlighting the pro-thrombotic nature of SARS-CoV-2, Dr. Greenwood said.
 

Injury patterns different

Three hundred and forty-two patients with COVID-19 and elevated troponin levels (COVID+/troponin+) across 25 centers were enrolled between June 2020 and March 2021 in COVID-HEART, deemed an “urgent public health study” in the United Kingdom. The aim was to characterize myocardial injury and its associations and sequelae in convalescent patients after hospitalization with COVID-19.

Enrollment took place during the Wuhan and Alpha waves of COVID-19: before vaccination and when dexamethasone and anticoagulant protocols were emerging. All participants underwent CMR at a median of 21 days after discharge.

Two prospective control groups also were recruited: 64 patients with COVID-19 and normal troponin levels (COVID+/troponin−) and 113 without COVID-19 or elevated troponin matched by age and cardiovascular comorbidities (COVID−/comorbidity+).

Overall, participants’ median age was 61 years and 69% were men. Common comorbidities included hypertension (47%), obesity (43%), and diabetes (25%).

The frequency of any heart abnormality – for example, left or right ventricular impairment, scar, or pericardial disease – was twice as great (61%) in COVID+/troponin+ cases, compared with controls (36% for COVID+/troponin− patients versus 31% for COVID−/comorbidity+ patients).

Specifically, more cases than controls had ventricular impairment (17.2% vs. 3.1% and 7.1%) or scar (42% vs. 7% and 23%).

The myocardial injury pattern differed between cases and controls, with cases more likely to have infarction (13% vs. 2% and 7%) or microinfarction (9% vs. 0% and 1%).

However, there was no between-group difference in nonischemic scar (13% vs. 5% and 14%).

The prevalence of probable recent myocarditis was 6.7% in cases, compared with 1.7% in controls without COVID-19 – “much lower” than in previous studies, Dr. Greenwood noted.

During follow-up, four COVID+/troponin+ patients (1.2%) died, and 34 (10%) experienced a subsequent major adverse cardiovascular event (MACE; 10.2%), which was similar to controls (6.1%).

Myocardial scar, but not previous COVID-19 infection or troponin level, was an independent predictor of MACE (odds ratio, 2.25).

“These findings suggest that macroangiopathic and microangiopathic thrombosis may be the key pathologic process for myocardial injury in COVID-19 survivors,” the authors conclude.

Dr. Greenwood added, “We are currently analyzing the 6-month follow-up CMR scans, the quality-of-life questionnaires, and the 6-minute walk tests. These will give us great understanding of how the heart repairs after acute myocardial injury associated with COVID-19. It will also allow us to assess the impact on patient quality of life and functional capacity.”
 

‘Tour de force’

James A. de Lemos, MD, co-chair of the American Heart Association’s COVID-19 CVD Registry Steering Committee and a professor of medicine at the University of Texas Southwestern Medical Center, Dallas, said, “This is a tour de force collaboration – obtaining this many MRIs across multiple centers in the pandemic is quite remarkable. The study highlights the multiple different processes that lead to cardiac injury in COVID patients, complements autopsy studies and prior smaller MRI studies, [and] also provides the best data on the rate of myocarditis to date among the subset of COVID patients with cardiac injury.”

Overall, he said, the findings “do support closer follow-up for patients who had COVID and elevated troponins. We need to see follow-up MRI results in this cohort, as well as longer term outcomes. We also need studies on newer, more benign variants that are likely to have lower rates of cardiac injury and even fewer MRI abnormalities.”

Matthias Stuber, PhD, and Aaron L. Baggish, MD, both of Lausanne University Hospital and University of Lausanne, Switzerland, noted in a related editorial, “We are also reminded that the clinical severity of COVID-19 is most often dictated by the presence of pre-existing comorbidity, with antecedent ischemic scar now added to the long list of bad actors. Although not the primary focus of the COVID-HEART study, the question of whether cardiac troponin levels should be checked routinely and universally during the index admission for COVID-19 remains unresolved,” they noted.

“In general, we are most effective as clinicians when we use tests to confirm or rule out the specific disease processes suspected by careful basic clinical assessment rather than in a shotgun manner among undifferentiated all-comers,” they conclude.

No commercial funding or relevant financial relationships were reported.

A version of this article originally appeared on Medscape.com.

About two-thirds of people with type 1 diabetes in the United States have overweight or obesity, nearly the same proportion as Americans without diabetes, new nationwide survey data suggest.

What’s more, among people with overweight or obesity, those with type 1 diabetes are less likely to receive lifestyle recommendations from health care professionals than those with type 2 diabetes, and are less likely to actually engage in lifestyle weight management activities than others with overweight or obesity, with or without type 2 diabetes.

“Among U.S. adults with type 1 diabetes, the burden of overweight and obesity is substantial and remains poorly managed,” write Michael Fang, PhD, of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues.

Their data, from the National Health Interview Survey (NHIS), were published online in Annals of Internal Medicine.

The need for insulin complicates weight management in people with type 1 diabetes because changes in diet and physical activity typically require adjustments to insulin timing and dosage to prevent hypoglycemia. There is little evidence to guide this for weight management, Dr. Fang and colleagues explain.

Consequently, “the lack of evidence for safe, effective methods of diet- and exercise-based weight control in people with type 1 diabetes may be keeping doctors from recommending such methods,” Dr. Fang said in a statement.

“Large clinical trials have been done in type 2 diabetes patients to establish guidelines for diet- and exercise-based weight management, and we now need something similar for type 1 diabetes patients.”  

Asked to comment, M. Sue Kirkman, MD, told this news organization: “The days when we could teach simple concepts about diabetes type like ‘those with type 1 are lean and those with type 2 are overweight’ are long gone. … Of concern, fewer adults with type 1 diabetes and overweight/obesity report that they are engaging in physical activity or caloric restriction than those without diabetes or those with type 2 diabetes.”

There are several likely reasons for the low rates of obesity/overweight lifestyle modification advice and implementation for those with type 1 diabetes, noted Dr. Kirkman, of the University of North Carolina at Chapel Hill, who coauthored joint American/European guidance on type 1 diabetes management.

“Medical visits are often primarily focused on glycemic management and complications screening, and we know that physicians in general are not very knowledgeable about how to counsel people – even those without diabetes – on weight loss. When you add in potential worries, real or not, about hypoglycemia, ketosis with carbohydrate restriction … it’s no wonder that this may not be addressed in busy visits.”

She also observed, “In years of going to diabetes meetings, I’ve noticed occasional sessions on managing ‘elite athletes’ with type 1 diabetes, but rarely are there sessions on how to counsel people about everyday healthy living.”
 

Many with type 1 diabetes have overweight/obesity

Dr. Fang and colleagues analyzed NHIS data for the years 2016, 2017, 2019, 2020, and 2021, when diabetes subtype data were available, for 128,571 adults. Diabetes type and height/weight data were self-reported. In the 2016, 2017, and 2020 surveys, participants were asked whether their physicians had recommended increasing physical activity and/or reducing calorie or fat consumption, and whether they were currently engaging in those activities.

The study population comprised 733 people with type 1 diabetes, 12,397 with type 2 diabetes, and 115,441 without diabetes. The proportions with overweight (body mass index, 25 to < 30 kg/m²) or obesity (≥ 30 kg/m²) were 62% among those with type 1 diabetes and 64% among those without diabetes, compared with 86% among those with type 2 diabetes.

Among those with overweight or obesity, the proportions who reported having received lifestyle recommendations were greatest among those with type 2 diabetes and least among those without diabetes, with the type 1 diabetes group in the middle.

After adjustment for age, sex, and race/ethnicity, the adjusted prevalence of receiving a provider recommendation to increase physical activity was 60% for those with type 2 diabetes, 54% for type 1 diabetes, and 44% for those without diabetes. Proportions for receiving recommendations for reducing fat/caloric intake were similar, at 60%, 51%, and 41%, respectively.

The proportions who reported actually engaging in lifestyle activities for weight management were lowest among those with type 1 diabetes, with 52% and 56% of them reporting having increased their physical activity and reducing fat/calories, respectively, compared with proportions ranging from 56% to 63% among the other two groups.

Regarding those findings, Dr. Kirkman commented, “In addition to the factors regarding physician interactions, people with type 1 diabetes may see this as a lower-priority health issue after years of being told that glucose control is the main priority.”

“I also wonder if the many, many tasks people with type 1 diabetes must do every day to manage their diabetes – along with other life issues all adults face – mean that there is just too much on the plate to add more lifestyle changes,” she added.

Asked about the potential for off-label use of glucagonlike peptide–1 agonists for weight management for people with type 1 diabetes, Dr. Kirkman said they could probably help some patients. However, she also pointed to two clinical trials in which liraglutide added to insulin therapy helped with glycemic control and weight reduction, but also increased the risk for hypoglycemia and diabetic ketoacidosis.

“It’s really important that researchers engage with adults with type 1 diabetes to better understand the unique priorities and barriers they face in addressing body weight,” Dr. Kirkman said.

Senior study author Elizabeth Selvin, PhD, professor of epidemiology at the Bloomberg School, said in the statement: “Our study busts the myth that people with type 1 diabetes are not being affected by the global obesity epidemic. … These findings should be a wake-up call that we need to be aggressive in addressing the obesity epidemic in persons with type 1 diabetes.”

The study was funded by the U.S. National Institutes of Health. Dr. Fang and Dr. Kirkman have reported no relevant financial relationships. Dr. Selvin has reported receiving royalty payments from Wolters Kluwer for chapters and laboratory monographs in UpToDate. She also reports receiving honoraria for editorial work on journals published by the American Diabetes Association and European Association for the Study of Diabetes.

A version of this article originally appeared on Medscape.com.

About two-thirds of people with type 1 diabetes in the United States have overweight or obesity, nearly the same proportion as Americans without diabetes, new nationwide survey data suggest.

What’s more, among people with overweight or obesity, those with type 1 diabetes are less likely to receive lifestyle recommendations from health care professionals than those with type 2 diabetes, and are less likely to actually engage in lifestyle weight management activities than others with overweight or obesity, with or without type 2 diabetes.

“Among U.S. adults with type 1 diabetes, the burden of overweight and obesity is substantial and remains poorly managed,” write Michael Fang, PhD, of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues.

Their data, from the National Health Interview Survey (NHIS), were published online in Annals of Internal Medicine.

The need for insulin complicates weight management in people with type 1 diabetes because changes in diet and physical activity typically require adjustments to insulin timing and dosage to prevent hypoglycemia. There is little evidence to guide this for weight management, Dr. Fang and colleagues explain.

Consequently, “the lack of evidence for safe, effective methods of diet- and exercise-based weight control in people with type 1 diabetes may be keeping doctors from recommending such methods,” Dr. Fang said in a statement.

“Large clinical trials have been done in type 2 diabetes patients to establish guidelines for diet- and exercise-based weight management, and we now need something similar for type 1 diabetes patients.”  

Asked to comment, M. Sue Kirkman, MD, told this news organization: “The days when we could teach simple concepts about diabetes type like ‘those with type 1 are lean and those with type 2 are overweight’ are long gone. … Of concern, fewer adults with type 1 diabetes and overweight/obesity report that they are engaging in physical activity or caloric restriction than those without diabetes or those with type 2 diabetes.”

There are several likely reasons for the low rates of obesity/overweight lifestyle modification advice and implementation for those with type 1 diabetes, noted Dr. Kirkman, of the University of North Carolina at Chapel Hill, who coauthored joint American/European guidance on type 1 diabetes management.

“Medical visits are often primarily focused on glycemic management and complications screening, and we know that physicians in general are not very knowledgeable about how to counsel people – even those without diabetes – on weight loss. When you add in potential worries, real or not, about hypoglycemia, ketosis with carbohydrate restriction … it’s no wonder that this may not be addressed in busy visits.”

She also observed, “In years of going to diabetes meetings, I’ve noticed occasional sessions on managing ‘elite athletes’ with type 1 diabetes, but rarely are there sessions on how to counsel people about everyday healthy living.”
 

Many with type 1 diabetes have overweight/obesity

Dr. Fang and colleagues analyzed NHIS data for the years 2016, 2017, 2019, 2020, and 2021, when diabetes subtype data were available, for 128,571 adults. Diabetes type and height/weight data were self-reported. In the 2016, 2017, and 2020 surveys, participants were asked whether their physicians had recommended increasing physical activity and/or reducing calorie or fat consumption, and whether they were currently engaging in those activities.

The study population comprised 733 people with type 1 diabetes, 12,397 with type 2 diabetes, and 115,441 without diabetes. The proportions with overweight (body mass index, 25 to < 30 kg/m²) or obesity (≥ 30 kg/m²) were 62% among those with type 1 diabetes and 64% among those without diabetes, compared with 86% among those with type 2 diabetes.

Among those with overweight or obesity, the proportions who reported having received lifestyle recommendations were greatest among those with type 2 diabetes and least among those without diabetes, with the type 1 diabetes group in the middle.

After adjustment for age, sex, and race/ethnicity, the adjusted prevalence of receiving a provider recommendation to increase physical activity was 60% for those with type 2 diabetes, 54% for type 1 diabetes, and 44% for those without diabetes. Proportions for receiving recommendations for reducing fat/caloric intake were similar, at 60%, 51%, and 41%, respectively.

The proportions who reported actually engaging in lifestyle activities for weight management were lowest among those with type 1 diabetes, with 52% and 56% of them reporting having increased their physical activity and reducing fat/calories, respectively, compared with proportions ranging from 56% to 63% among the other two groups.

Regarding those findings, Dr. Kirkman commented, “In addition to the factors regarding physician interactions, people with type 1 diabetes may see this as a lower-priority health issue after years of being told that glucose control is the main priority.”

“I also wonder if the many, many tasks people with type 1 diabetes must do every day to manage their diabetes – along with other life issues all adults face – mean that there is just too much on the plate to add more lifestyle changes,” she added.

Asked about the potential for off-label use of glucagonlike peptide–1 agonists for weight management for people with type 1 diabetes, Dr. Kirkman said they could probably help some patients. However, she also pointed to two clinical trials in which liraglutide added to insulin therapy helped with glycemic control and weight reduction, but also increased the risk for hypoglycemia and diabetic ketoacidosis.

“It’s really important that researchers engage with adults with type 1 diabetes to better understand the unique priorities and barriers they face in addressing body weight,” Dr. Kirkman said.

Senior study author Elizabeth Selvin, PhD, professor of epidemiology at the Bloomberg School, said in the statement: “Our study busts the myth that people with type 1 diabetes are not being affected by the global obesity epidemic. … These findings should be a wake-up call that we need to be aggressive in addressing the obesity epidemic in persons with type 1 diabetes.”

The study was funded by the U.S. National Institutes of Health. Dr. Fang and Dr. Kirkman have reported no relevant financial relationships. Dr. Selvin has reported receiving royalty payments from Wolters Kluwer for chapters and laboratory monographs in UpToDate. She also reports receiving honoraria for editorial work on journals published by the American Diabetes Association and European Association for the Study of Diabetes.

A version of this article originally appeared on Medscape.com.

About two-thirds of people with type 1 diabetes in the United States have overweight or obesity, nearly the same proportion as Americans without diabetes, new nationwide survey data suggest.

What’s more, among people with overweight or obesity, those with type 1 diabetes are less likely to receive lifestyle recommendations from health care professionals than those with type 2 diabetes, and are less likely to actually engage in lifestyle weight management activities than others with overweight or obesity, with or without type 2 diabetes.

“Among U.S. adults with type 1 diabetes, the burden of overweight and obesity is substantial and remains poorly managed,” write Michael Fang, PhD, of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues.

Their data, from the National Health Interview Survey (NHIS), were published online in Annals of Internal Medicine.

The need for insulin complicates weight management in people with type 1 diabetes because changes in diet and physical activity typically require adjustments to insulin timing and dosage to prevent hypoglycemia. There is little evidence to guide this for weight management, Dr. Fang and colleagues explain.

Consequently, “the lack of evidence for safe, effective methods of diet- and exercise-based weight control in people with type 1 diabetes may be keeping doctors from recommending such methods,” Dr. Fang said in a statement.

“Large clinical trials have been done in type 2 diabetes patients to establish guidelines for diet- and exercise-based weight management, and we now need something similar for type 1 diabetes patients.”  

Asked to comment, M. Sue Kirkman, MD, told this news organization: “The days when we could teach simple concepts about diabetes type like ‘those with type 1 are lean and those with type 2 are overweight’ are long gone. … Of concern, fewer adults with type 1 diabetes and overweight/obesity report that they are engaging in physical activity or caloric restriction than those without diabetes or those with type 2 diabetes.”

There are several likely reasons for the low rates of obesity/overweight lifestyle modification advice and implementation for those with type 1 diabetes, noted Dr. Kirkman, of the University of North Carolina at Chapel Hill, who coauthored joint American/European guidance on type 1 diabetes management.

“Medical visits are often primarily focused on glycemic management and complications screening, and we know that physicians in general are not very knowledgeable about how to counsel people – even those without diabetes – on weight loss. When you add in potential worries, real or not, about hypoglycemia, ketosis with carbohydrate restriction … it’s no wonder that this may not be addressed in busy visits.”

She also observed, “In years of going to diabetes meetings, I’ve noticed occasional sessions on managing ‘elite athletes’ with type 1 diabetes, but rarely are there sessions on how to counsel people about everyday healthy living.”
 

Many with type 1 diabetes have overweight/obesity

Dr. Fang and colleagues analyzed NHIS data for the years 2016, 2017, 2019, 2020, and 2021, when diabetes subtype data were available, for 128,571 adults. Diabetes type and height/weight data were self-reported. In the 2016, 2017, and 2020 surveys, participants were asked whether their physicians had recommended increasing physical activity and/or reducing calorie or fat consumption, and whether they were currently engaging in those activities.

The study population comprised 733 people with type 1 diabetes, 12,397 with type 2 diabetes, and 115,441 without diabetes. The proportions with overweight (body mass index, 25 to < 30 kg/m²) or obesity (≥ 30 kg/m²) were 62% among those with type 1 diabetes and 64% among those without diabetes, compared with 86% among those with type 2 diabetes.

Among those with overweight or obesity, the proportions who reported having received lifestyle recommendations were greatest among those with type 2 diabetes and least among those without diabetes, with the type 1 diabetes group in the middle.

After adjustment for age, sex, and race/ethnicity, the adjusted prevalence of receiving a provider recommendation to increase physical activity was 60% for those with type 2 diabetes, 54% for type 1 diabetes, and 44% for those without diabetes. Proportions for receiving recommendations for reducing fat/caloric intake were similar, at 60%, 51%, and 41%, respectively.

The proportions who reported actually engaging in lifestyle activities for weight management were lowest among those with type 1 diabetes, with 52% and 56% of them reporting having increased their physical activity and reducing fat/calories, respectively, compared with proportions ranging from 56% to 63% among the other two groups.

Regarding those findings, Dr. Kirkman commented, “In addition to the factors regarding physician interactions, people with type 1 diabetes may see this as a lower-priority health issue after years of being told that glucose control is the main priority.”

“I also wonder if the many, many tasks people with type 1 diabetes must do every day to manage their diabetes – along with other life issues all adults face – mean that there is just too much on the plate to add more lifestyle changes,” she added.

Asked about the potential for off-label use of glucagonlike peptide–1 agonists for weight management for people with type 1 diabetes, Dr. Kirkman said they could probably help some patients. However, she also pointed to two clinical trials in which liraglutide added to insulin therapy helped with glycemic control and weight reduction, but also increased the risk for hypoglycemia and diabetic ketoacidosis.

“It’s really important that researchers engage with adults with type 1 diabetes to better understand the unique priorities and barriers they face in addressing body weight,” Dr. Kirkman said.

Senior study author Elizabeth Selvin, PhD, professor of epidemiology at the Bloomberg School, said in the statement: “Our study busts the myth that people with type 1 diabetes are not being affected by the global obesity epidemic. … These findings should be a wake-up call that we need to be aggressive in addressing the obesity epidemic in persons with type 1 diabetes.”

The study was funded by the U.S. National Institutes of Health. Dr. Fang and Dr. Kirkman have reported no relevant financial relationships. Dr. Selvin has reported receiving royalty payments from Wolters Kluwer for chapters and laboratory monographs in UpToDate. She also reports receiving honoraria for editorial work on journals published by the American Diabetes Association and European Association for the Study of Diabetes.

A version of this article originally appeared on Medscape.com.

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large