Richard M. Nowak

Henry Ford Health System, Detroit, Michigan, United States

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Publications (238)1433.59 Total impact

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    ABSTRACT: Copeptin has demonstrated a role in early rule out for acute myocardial infarction (AMI) in combination with a negative troponin. However, management of patients with chest pain with a positive copeptin in the setting of a negative troponin is unclear. The multicentre CHOPIN trial enrolled 2071 patients with acute chest pain. Of these, 476 subjects with an initial negative troponin but an elevated copeptin (>14 pmol/L) were included in this study. Copeptin and troponin levels were rechecked at 2 h and the final diagnosis of AMI was made by two independent, blinded cardiologists. Follow-up at 30 days was obtained for major adverse cardiac events (MACEs), including death, AMI and urgent revascularisation. Of the 476 patients analysed, 365 (76.7%) had a persistently elevated copeptin at 2 h and 111 patients (23.3%) had a copeptin that fell below the cut-off of 14 pmol/L. When the second copeptin was elevated there were 18 AMIs (4.9%) compared with 0 (0%) when the second copeptin was negative (p=0.017), yielding a negative predictive value of 100% (95% CI 96.7% to 100%). On 30-day follow-up there were 36 MACEs (9.9%) in the positive second copeptin group and 2 (1.8%) MACEs in the negative second copeptin group (p=0.006). Patients with chest pain with an initial negative troponin but positive copeptin are common and carry an intermediate risk of AMI. A second copeptin drawn 2 h after presentation may help risk stratify and potentially rule out AMI in this cohort. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Emergency Medicine Journal 06/2015; DOI:10.1136/emermed-2015-204692
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    ABSTRACT: Chest pain is a common complaint to emergency departments (EDs) and clinical risk factors are used to predict which patients are at risk for worse outcomes and mortality. The goal was to assess the novel biomarker midregional proadrenomedullin (MR-proADM) in prediction of mortality and major adverse cardiac events (MACE). This was a subanalysis of the CHOPIN study, a 16-center prospective trial that enrolled 2,071 patients presenting with chest pain within 6 hours of onset. The primary endpoint was 6-month all-cause mortality and the secondary endpoint was 30-day and 6-month MACE: ED visits or hospitalization for acute myocardial infarction, unstable angina, reinfarction, revascularization, and heart failure. MR-proADM performed similarly to troponin (cTnI; c-statistic = 0.845 and 0.794, respectively) for mortality prediction in all subjects and had similar results in those with noncardiac diagnoses. MR-proADM concentrations were stratified by decile, and the cohort in the top decile had a 9.8% 6-month mortality risk versus 0.9% risk for those in the bottom nine deciles (p < 0.0001). MR-proADM, history of coronary artery disease (CAD), and hypertension were predictors of short-term MACE, while history of CAD, hypertension, cTnI, and MR-proADM were predictors of long-term MACE. In patients with chest pain, MR-proADM predicts mortality and MACE in all-comers with chest pain and has similar prediction in those with a noncardiac diagnosis. This exploratory analysis is primarily hypotheses-generating and future prospective studies to identify its utility in risk stratification should be considered. © 2015 by the Society for Academic Emergency Medicine.
    Academic Emergency Medicine 04/2015; 22(5). DOI:10.1111/acem.12649
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    ABSTRACT: Hypertensive emergency has a high mortality risk and the treatment goal is to quickly lower blood pressure with intravenous (IV) medications. Characteristics that are associated with non-response to IV antihypertensives have not been identified. The objective is to identify patient characteristics associated with resistance to IV antihypertensives. This was a subanalysis of patients enrolled in the previously described comparative effectiveness trial of IV nicardipine vs. labetalol use in the emergency department (CLUE) study, a randomized trial of nicardipine vs. labetalol. Non-responders were defined as those patients who did not achieve target systolic blood pressure (SBP), as set by the treating physician, within thirty minutes of IV antihypertensive medication, +/- 20mmHg. Stepwise logistic regression was used to identify covariates associated with the measurement outcomes. CLUE enrolled 226 patients, 52.7% female, 76.4% black, mean age of 52.6±14.6 years, of whom 110 were treated with nicardipine and 116 with labetalol. The median (IQR) initial systolic blood pressure was 211mmHg (198, 226), 210 (200, 230), and 211mmHg (198, 226), for the total, non-responder, and responder cohorts, respectively (p-value=0.65, 95% CI [-5.8-11.3]). Twenty-nine were non-responders, 9 in the nicardipine and 20 in the labetalol group. In univariate analysis, several symptoms suggestive of end organ damage were associated with non-response. After multiple variable logistic regression (AUC = 0.72), treatment with labetalol (OR 2.7, 95% CI [1.1-6.7]), history of stroke (OR 5.4, 95% CI [1.6-18.5]), and being male (OR 3.3, 95% CI [1.4-8.1]) were associated with failure to achieve target blood pressure. Male gender and history of previous stroke are associated with difficult to control blood pressure.
    The western journal of emergency medicine 03/2015; 16(2):276-83. DOI:10.5811/westjem.2015.1.23308
  • Journal of the American College of Cardiology 03/2015; 65(10):A132. DOI:10.1016/S0735-1097(15)60132-2
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    ABSTRACT: Introduction: Copeptin has demonstrated a role in early rule out for acute myocardial infarction in combination with a negative troponin. However, the value of copeptin in patients with a positive troponin is not established. Hypothesis: The addition of a baseline copeptin at chest pain presentation will improve risk stratification in patients with mild troponin elevation. Methods: The multi-center CHOPIN trial enrolled 2071 acute chest pain patients. All subjects with ST segment elevations were excluded from this analysis. Of the remaining patients, 124 had a mildly elevated troponin (defined by <2x URL) and were included in the study cohort. Baseline cTnI and copeptin levels were drawn on presentation, and another cTnI at 2 hours. Copeptin ≤14 pmol/l and troponin deltas ≤10% from baseline were considered positive. Two independent blinded cardiologists adjudicated AMI diagnosis. The value of a baseline copeptin in this cohort was assessed using AMI incidence, odds ratio, sensitivity, and negative predictive value (NPV). Results: Of the 124 patients in the study cohort, 73 (59%) had an elevated copeptin and an associated AMI incidence of 25% (18 AMIs). The remaining 51 patients (41%) were copeptin negative and diagnosed with 3 AMIs, an incidence of 5.9% (p = 0.006, figure 1). A positive copeptin increased the likelihood of AMI diagnosis with an odds ratio of 5.3 (95% CI: 1.5-19.2). The sensitivity and NPV for AMI were 86% and 94%, both of which were higher than the delta troponin (table 1). When an initial copeptin was combined with the delta troponin the sensitivity and NPV for AMI improved to 100%. Conclusion: Use of copeptin in chest pain patients with mild troponin elevation provides further risk stratification. The combination of copeptin with a delta troponin may aid in earlier AMI rule out in this subset of patients. This approach could be especially relevant as the increasing use of high sensitivity troponin assays leads to greater rates of mild troponin elevations.
    Circulation 11/2014; 130(Suppl 2):A13996.
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    ABSTRACT: Noninvasive hemodynamic (HD) assessments in the emergency department (ED) might assist in the diagnosis, therapeutic plan development and risk stratification of acutely ill patients. This multinational observational study was designed to initiate noninvasive HD measurements prior to any ED patient therapeutic interventions and broadly evaluate them for potential diagnostic, therapeutic and predictive value. We enrolled patients with suspected acute heart failure (AHF), sepsis or stroke. Continuous noninvasive HD monitoring was begun using the Nexfin finger cuff device (Edwards LifeSciences, BMEYE, Amsterdam, Netherlands). Beat-to-beat HD measurements were averaged for the initial 15 minutes, prior to therapeutic intervention. We performed suspected disease group comparisons and evaluated HD predictors of 30-day mortality. Of 510 patients enrolled: 185 (36%) AHF, 194 (38%) sepsis and 131 (26%) stroke. HD variables were significantly different (p<0.05) amongst the groups. Cardiac output and index and stroke volume index (SVI) were highest in sepsis (6.5, 3.5, 36), followed by stroke (5.5, 2.7, 35.8), and lowest in AHF (5.4, 2.7, 33.6). The in-group HD standard deviations and ranges measurements were large, indicating heterogeneous underlying HD profiles. Presenting SVI predicted 30-day mortality for all groups. Presenting ED noninvasive HD data has not been previously reported in any large patient population. Our data suggest a potential role for early noninvasive HD assessments aiding in diagnosing of patients, individualizing therapy based on each person's unique HD values and predicting 30-day mortality. Further studies and analyses are needed to determine how HD assessments should be best used in the ED.
    The western journal of emergency medicine 11/2014; 15(7):786-94. DOI:10.5811/westjem.2014.8.21357
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    ABSTRACT: Patients with frequent asthma exacerbations resulting in emergency department (ED) visits are at increased risk for future exacerbations. We examined the ability of 1 dose of benralizumab, an investigational antiinterleukin 5 receptor α monoclonal antibody, to reduce recurrence after acute asthma exacerbations. In this randomized, double-blind, placebo-controlled study, eligible subjects presented to the ED with an asthma exacerbation, had partial response to treatment, and greater than or equal to 1 additional exacerbation within the previous year. Subjects received 1 intravenous infusion of placebo (n = 38) or benralizumab (0.3 mg/kg, n = 36 or 1.0 mg/kg, n = 36) added to outpatient management. The primary outcome was the proportion of subjects with greater than or equal to 1 exacerbation at 12 weeks in placebo vs the combined benralizumab groups. Other outcomes included the time-weighted rate of exacerbations at week 12, adverse events, blood eosinophil counts, asthma symptom changes, and health care resource utilization. The proportion of subjects with greater than or equal to 1 asthma exacerbation at 12 weeks was not different between placebo and the combined benralizumab groups (38.9% vs 33.3%; P = .67). However, compared with placebo, benralizumab reduced asthma exacerbation rates by 49% (3.59 vs 1.82; P = .01) and exacerbations resulting in hospitalization by 60% (1.62 vs 0.65; P = .02) in the combined groups. Benralizumab reduced blood eosinophil counts but did not affect other outcomes, while demonstrating an acceptable safety profile. When added to usual care, 1 dose of benralizumab reduced the rate and severity of exacerbations experienced over 12 weeks by subjects who presented to the ED with acute asthma. Copyright © 2014 Elsevier Inc. All rights reserved.
    American Journal of Emergency Medicine 10/2014; DOI:10.1016/j.ajem.2014.09.036
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    ABSTRACT: We investigated absolute and relative cardiac troponin I (TnI) delta changes, optimal sampling protocols, and decision thresholds for early diagnosis of myocardial infarction (MI). Serial cardiac biomarker values demonstrating a rise and/or fall define MI diagnosis; however the magnitude of change, timing, and diagnostic accuracy of absolute versus relative (percentage) deltas remains unsettled.
    Clinical Biochemistry 09/2014; 48(4-5). DOI:10.1016/j.clinbiochem.2014.09.012
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    ABSTRACT: To compare emergency department TnI serial sampling intervals, determine optimal diagnostic thresholds, and report representative diagnostic performance characteristics for early rule-in and rule-out of MI.
    Clinical Biochemistry 09/2014; 48(4-5). DOI:10.1016/j.clinbiochem.2014.08.018
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    ABSTRACT: Introduction Non-invasive, continuous hemodynamic monitoring is entering the clinical arena. The primary objective of this study was to test the feasibility of such monitoring in a pilot sample of Emergency Department (ED) stroke patients. Secondary objectives included analysis of hemodynamic variability and correlation of continuous blood pressure measurements with standard measurements. Methods This study was a secondary analysis of 7 stroke patients from a prospectively collected data set of patients that received 2 hours of hemodynamic monitoring in the ED. Stroke patients were included if hemorrhagic or ischemic stroke was confirmed by neuroimaging, and symptom onset was within 24 hours. They were excluded for the presence of a stroke mimic or transient ischemic attack. Monitoring was performed using the Nexfin device (Edwards Lifesciences, Irvine CA). Results The mean age of the cohort was 71 ± 17 years, 43% were male, and the mean National Institute of Health Stroke Scale (NIHSS) was 6.9 ± 5.5. Two patients had hemorrhagic stroke. We obtained 42,456 hemodynamic data points, including beat-to-beat blood pressure measurements with variability of 18 mmHg and cardiac indices ranging from 1.8 to 3.6 l/min/m2. The correlation coefficient between continuous blood pressure measurements with the Nexfin device and standard ED readings was 0.83. Conclusion This exploratory investigation revealed that continuous, noninvasive monitoring in the ED is feasible in acute stroke. Further research is currently underway to determine how such monitoring may impact outcomes in stroke or replace the need for invasive monitoring.
    The western journal of emergency medicine 07/2014; 15(4):345-50. DOI:10.5811/westjem.2014.4.16131
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    ABSTRACT: Study Objectives: To compare the safety and efficacy of US Food and Drug Administration (FDA)-recommended doses of labetalol and nicardipine for hypertension (HTN) management in a subset of patients with renal dysfunction (RD). Design: Randomized, open label, multicenter prospective clinical trial. Setting: Thirteen United States tertiary care emergency departments. Patients or Participants: Subgroup analysis of the Evaluation of IV Cardene (Nicardipine) and Labetalol Use in the Emergency Department (CLUE) clinical trial. The subjects were 104 patients with RD (ie, creatinine clearance, < 75 mL/min) who presented to the emergency department with a systolic blood pressure (SBP) >= 180 mmHg on 2 consecutive readings and for whom the emergency physician felt intravenous antihypertensive therapy was desirable. Interventions: The FDA recommended doses of either labetalol or nicardipine for HTN management. Measurements: The number of patients achieving the physician's predefined target SBP range within 30 minutes of treatment. Results: Patients treated with nicardipine were within target range more often than those receiving labetalol (92% vs 78%, P = 0.046). On 6 SBP measures, patients treated with nicardipine were more likely to achieve the target range on either 5 or all 6 readings than were patients treated with labetalol (46% vs 25%, P = 0.024). Labetalol patients were more likely to require rescue medication (27% vs 17%, P = 0.020). Adverse events thought to be related to either treatment group were not reported in the 30-minute active study period, and patients had slower heart rates at all time points after 5 minutes (P < 0.01). Conclusions: In severe HTN with RD, nicardipine-treated patients are more likely to reach a target blood pressure range within 30 minutes than are patients receiving labetalol. Clinical Implications: Within 30 minutes of administration, nicardipine is more efficacious than labetalol for acute blood pressure control in patients with RD.
    Postgraduate Medicine 07/2014; 126(4):124-130. DOI:10.3810/pgm.2014.07.2790
  • Christine B. Davis, Richard M. Nowak
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    ABSTRACT: Clinical problem This a case of non-traumatic shoulder pain initially diagnosed on x-ray as an anterior dislocation. The patient was on anticoagulants and in actuality had severe hemarthrosis that caused the subluxation. Attempts to reduce the dislocation in this situation might have resulted in worsening of the intra-articular bleed. Analysis of literature review There has been only one similar reported case in the European Journal of Emergency Medicine in 2013 of a 53-year-old woman who was thought to have a nontraumatic anterior shoulder dislocation and attempts were unsuccessful at reduction. Definitive therapy involved hemarthrosis aspiration. Others have reported spontaneous hemarthrosis due to anticoagulants, however, only one has reported an initial mistaken joint dislocation diagnosis. Summary Non-traumatic hemarthrosis do occur in patients on anticoagulant therapy and it is important to recognize that this can be misdiagnosed as a joint dislocation requiring reduction. In a patient who is on anticoagulants presenting with nontraumatic joint pain and anterior shoulder or possibly other dislocations on plain radiographs, it is pertinent to consider hemarthrosis.
    American Journal of Emergency Medicine 06/2014; DOI:10.1016/j.ajem.2014.05.042
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    ABSTRACT: Background Dyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the emergency department (ED) phase of management.Objectives The aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e., five-point absolute Likert scale, 10-cm visual analog scale [VAS], or seven-point relative Likert scale).Methods This was a post hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within 1 hour of first physician encounter. Inclusion criteria were broad to reflect real-world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling-based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement.ResultsOf the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, although there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five-point Likert scale (c-index ranged from 0.708 to 0.831 for each scale).Conclusions Predictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.ResumenAntecedentesLa disnea es el síntoma más frecuente en la insuficiencia cardiaca aguda (ICA), sin embargo no ha sido bien definida la mejor manera de medirla. Estudios previos demuestran diferencias en la mejoría de la disnea a través de varias escalas de medida, sin embargo estos estudios suelen reclutar pacientes bastante después de la fase de manejo en el SU.ObjetivosEl objetivo de este estudio fue determinar los predictores precoces de mejoría de la disnea para tres escalas de disnea diferentes frecuentemente utilizadas (escala Likert absoluta de 5 puntos, escala visual analógica [EVA] de 10 cm o escala Likert relativa de 7 puntos).MétodosSe trata de un análisis post hoc del estudio observacional Disnea URGENTE, que reclutó 776 pacientes dentro de la primera hora tras la primera valoración médica en 17 países. Los criterios de inclusión fueron amplios para reflejar la práctica clínica en el mundo real. La literatura previa documentó la definición a priori de la mejoría significativa de disnea. Se crearon modelos multivariables basados en el remuestreo para determinar las características de los pacientes significativamente asociadas con la mejoría de la disnea.ResultadosDe los 524 pacientes con ICA, aproximadamente un 40% de los pacientes no documentaron una mejoría sustancial de la disnea en las 6 primeras horas. Las características basales fueron similares entre los que mejoraron y los que no, aunque hubo diferencias en la historia de insuficiencia cardiaca, enfermedad coronaria y presión arterial sistólica inicial. Para aquéllos que mejoraron, las características del paciente difirieron en las tres escalas, con la excepción de la gravedad de la disnea basal para la EVA y en la escala Likert de 5 puntos (el índice-c varió desde 0,708 hasta 0,831 para cada escala).ConclusionesLos predictores de la mejoría precoz de disnea difieren dependiendo de la escala, con la excepción de la disnea basal. Los intentos para utilizar una sola escala para categorizar la totalidad del síntoma disnea pueden ser insuficientes.
    Academic Emergency Medicine 06/2014; 21(6). DOI:10.1111/acem.12390
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    ABSTRACT: Elevated blood pressure is present in more than 60% of patients with acute stroke. Moderate to severe hypertension affects stroke outcomes, yet the optimal management has been a gray area in the care of such patients. Although new data are changing the approach, particularly for hemorrhagic events, significant questions remain. This article presents the latest evidence on hypertension in the setting of ischemic and hemorrhagic stroke and highlights management considerations that are relevant to emergency medicine.
    Annals of emergency medicine 04/2014; 64(3). DOI:10.1016/j.annemergmed.2014.03.004
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    ABSTRACT: Abstract Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).
    Academic Emergency Medicine 04/2014; 21(4). DOI:10.1111/acem.12341
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    Journal of the American College of Cardiology 04/2014; 63(12 S). DOI:10.1016/S0735-1097(14)60202-3
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    Journal of the American College of Cardiology 04/2014; 63(12 S). DOI:10.1016/S0735-1097(14)60266-7
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    Journal of the American College of Cardiology 04/2014; 63(12 S). DOI:10.1016/S0735-1097(14)60058-9
  • Richard M. Nowak, Charles G. Macias
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    ABSTRACT: Although most cases of anaphylaxis are treated in the emergency department (ED), personnel may not immediately recognize anaphylaxis based on presenting symptoms because it has a wide range of clinical manifestations and variable progression. When symptoms happen to be atypical or mild and when no trigger is identified, the diagnosis of anaphylaxis can be challenging. Underdiagnosis of anaphylaxis can lead to delayed use of appropriate first-line epinephrine in favor of treatments that should be used as adjunctive only. Even when anaphylaxis is recognized, the choice between an epinephrine autoinjector or epinephrine ampule can still present a challenge. Treatment of anaphylaxis in the ED should include a combination of intramuscular epinephrine, supplemental oxygen, and intravenous fluids. If there is an incomplete response to the initial dose of epinephrine, additional doses or other measures may be considered. The most important management consideration is avoiding treatment delays, because symptoms can progress rapidly. Upon discharge from the ED, all patients with anaphylaxis should be given a prescription for at least 2 epinephrine autoinjectors, an initial emergency action plan, education about avoidance of triggers, and a referral to an allergist. A significant limitation of current studies is that clinical outcomes in anaphylaxis associated with established poor rates of diagnosis and use of recommended treatments are unclear; such trials must be conducted as supporting evidence for ED management guidelines for anaphylaxis.
    The American journal of medicine 01/2014; 127(1):S34–S44. DOI:10.1016/j.amjmed.2013.09.012
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    ABSTRACT: Background Patients with frequent asthma exacerbations resulting in emergency department (ED) visits are at increased risk for future exacerbations. We examined the ability of one dose of benralizumab, an investigational anti-interleukin-5 receptor α monoclonal antibody, to reduce recurrence following acute asthma exacerbations. Methods In this randomized, double-blind, placebo-controlled study, eligible subjects presented to the ED with an asthma exacerbation, had partial response to treatment, and ≥ 1 additional exacerbation within the previous year. Subjects received one intravenous infusion of placebo (n = 38) or benralizumab (0.3 mg/kg, n = 36 or 1.0 mg/kg, n = 36) added to outpatient management. The primary outcome was the proportion of subjects with ≥ 1 exacerbation at 12 weeks in placebo vs the combined benralizumab groups. Other outcomes included the time-weighted rate of exacerbations at week 12, adverse events, blood eosinophil counts, asthma symptom changes, and healthcare resource utilization. Results The proportion of subjects with ≥ 1 asthma exacerbation at 12 weeks was not different between placebo and the combined benralizumab groups (38.9% vs 33.3%; P= 0.67). However, compared with placebo, benralizumab reduced asthma exacerbation rates by 49% (3.59 vs 1.82; P= 0.01), and exacerbations resulting in hospitalization by 60% (1.62 vs 0.65; P= 0.02) in the combined groups. Benralizumab reduced blood eosinophil counts but did not affect other outcomes, while demonstrating an acceptable safety profile. Conclusions When added to usual care, one dose of benralizumab reduced the rate and severity of exacerbations experienced over 12 weeks by subjects who presented to the ED with acute asthma.

Publication Stats

7k Citations
1,433.59 Total Impact Points

Institutions

  • 1992–2015
    • Henry Ford Health System
      • Department of Emergency Medicine
      Detroit, Michigan, United States
  • 2003–2014
    • University of California, San Diego
      • Division of Cardiology
      San Diego, California, United States
    • Duke University Medical Center
      Durham, North Carolina, United States
  • 1977–2014
    • Henry Ford Hospital
      • • Department of Emergency Medicine
      • • Department of Internal Medicine
      Detroit, Michigan, United States
  • 2013
    • Kansas City University of Medicine and Biosciences
      Kansas City, Missouri, United States
  • 2011–2013
    • Wayne State University
      Detroit, Michigan, United States
  • 2012
    • Wake Forest School of Medicine
      Winston-Salem, North Carolina, United States
  • 2007
    • The Ohio State University
      Columbus, Ohio, United States
  • 2006
    • University of California, Davis
      Davis, California, United States
  • 2002–2005
    • University of Oslo
      Kristiania (historical), Oslo, Norway
    • Emory University
      • Department of Emergency Medicine
      Atlanta, Georgia, United States
    • University of Missouri - Kansas City
      Kansas City, Missouri, United States
  • 2004
    • VA San Diego Healthcare System
      San Diego, California, United States
  • 1984
    • American college of Physicians
      Filadelfia, Pennsylvania, United States