Impact of Morphine Treatment on Infarct Size and Reperfusion Injury in Acute Reperfused ST-Elevation Myocardial Infarction

Abstract

Current evidence regarding the effect of intravenous morphine administration on reperfusion injury and/or cardioprotection in patients with myocardial infarction is conflicting. The aim of this study was to evaluate the impact of morphine administration, on infarct size and reperfusion injury assessed by cardiac magnetic resonance imaging (CMR) in a large multicenter ST-elevation myocardial infarction (STEMI) population. In total, 734 STEMI patients reperfused by primary percutaneous coronary intervention <12 h after symptom onset underwent CMR imaging at eight centers for assessment of myocardial damage. Intravenous morphine administration was recorded in all patients. CMR was completed within one week after infarction using a standardized protocol. The clinical endpoint of the study was the occurrence of major adverse cardiac events (MACE) within 12 months after infarction. Intravenous morphine was administered in 61.8% (n = 454) of all patients. There were no differences in infarct size (17%LV, interquartile range [IQR] 8–25%LV versus 16%LV, IQR 8–26%LV, p = 0.67) and microvascular obstruction (p = 0.92) in patients with versus without morphine administration. In the subgroup of patients with early reperfusion within 120 min and reduced flow of the infarcted vessel (TIMI-flow ≤2 before PCI) morphine administration resulted in significantly smaller infarcts (12%LV, IQR 12–19 versus 19%LV, IQR 10–29, p = 0.035) and reduced microvascular obstruction (p = 0.003). Morphine administration had no effect on hard clinical endpoints (log-rank test p = 0.74) and was not an independent predictor of clinical outcome in Cox regression analysis. In our large multicenter CMR study, morphine administration did not have a negative effect on myocardial damage or clinical prognosis in acute reperfused STEMI. In patients, presenting early ( ≤120 min) morphine may have a cardioprotective effect as reflected by smaller infarcts; but this finding has to be assessed in further well-designed clinical studies

Smoking, alcohol and opioids effect on coronary microcirculation: an update overview

“…Controversial reports on the impact of morphine and opioid agonists on mortality rate and myocardial damage post MI and PCI have been published suggesting a cardioprotective [ 158 – 160 ], adverse effect [ 161 – 163 ] or no significant change [ 164 , 165 ]. In reperfused STEMI patients, CMR analysis suggested contradictory results by different studies as no impact of morphine on microvascular obstruction (MVO) [ 165 ] versus an adverse effect exacerbating the myocardial and microvascular damage (MVO) post PCI [ 162 ]. Future clinical trials are warranted to assess the effect of opioids on coronary microvascular function in post MI and Post-PCI patients to determine the safety of using opioid analgesics for pain treatment of ischemic cardiovascular patients.…”

Correlations between Morphine Use and Adverse Outcomes in Acute ST-Segment Elevation Myocardial Infarction with Acute Heart Failure: a retrospective study 

“…The guidelines for the management of AMI in patients with STEMI continue to recommend intravenous morphine as a drug of choice for the alleviation of chest pain, with a class IIA indication [10]. Morphine administration is expected to reduce sympathetic tone and decrease venous return, which leads to increased cardiac workload [11] and results in smaller infarcts and signi cantly less microvascular obstruction determined by cardiac magnetic resonance [12]. Nevertheless, studies have revealed a correlation between morphine use and worse mortality.…”

Copeptin Levels Are Independent from Mild Therapeutic Hypothermia but Do Not Predict Infarct Size in Patients Presenting with ST-Segment Elevation Myocardial Infarction

“…Although patients were continuously controlled for shivering, it cannot be ruled out that subclinical shivering led to more stress in this group. Conversely, data from Eitel et al suggest a potential positive impact of opioids on infarct size and reperfusion injury in STEMI patients [22]. Although this effect was only seen in early presenters (≤120 min), central nervous effects of opioids may impact infarct size, and that may have diminished the effect of MTH.…”