Intravenous morphine use in acute heart failure increases adverse outcomes: a meta-analysis

Abstract

Intravenous morphine is a controversial treatment for acute heart failure (AHF). This study aimed to evaluate and compare the efficacy of intravenous morphine treatment vs. no morphine treatment in AHF patients. Relevant research conducted before June 2020 was retrieved from electronic databases. One unpublished study of our own was also included. Studies were eligible for inclusion if they compared AHF patients treated with intravenous morphine and patients who did not receive morphine. This meta-analysis included three propensity-matched cohorts and two retrospective analyses, involving a total of 149,967 patients (intravenous-morphine group, n = 22,072; no-morphine group, n = 127,895). There was a non-significant increase in the in-hospital mortality in the morphine group (combined odds ratio [OR] = 2.14, 95% confidence interval [CI]: 0.88-5.23, p = 0.095, I 2 = 97.1%). However, subgroup analyse showed that the rate of in-hospital mortality with odds of 1.41 times more likely (95% CI: 1.11-1.80, p = 0.005, I 2 = 0%) in those receiving vs. not receiving intravenous morphine. No significant correlation was found between intravenous morphine and invasive mechanical ventilation (OR = 2.19, 95% CI: 0.84-5.73, p = 0.10, I 2 = 94.2%; subgroup analysis: OR = 2.24, 95% CI: 0.70-7.21, p = 0.176, I 2 = 95.1%) or long-term mortality (hazard ratio = 1.15, 95% CI: 0.96-1.34, p = 0.335; I 2 = 8.6%). The administration of intravenous morphine to patients with AHF may be related to in-hospital mortality, but not to invasive mechanical ventilation and long-term mortality.

Effect of opioids for breathlessness in heart failure: a systematic review and meta-analysis

“…If administered at all, clinicians should be alert to stop treatment very soon in case of unresponsiveness and severe adverse events. Of note, for acute HF, in 2021 alone, three large studies reported that the use of opioids led to increased mortality in this population 25–27. A recent study from Domínguez-Rodríguez et al 28 found that morphine, compared with midazolam, doubled the incidence of adverse events when used to treat breathlessness in patients with HF.…”

Signal of harm in morphine use in adults with acute pulmonary oedema: A rapid systematic review

“…[12,13] Despite the theoretical benefits, lack of consensus and evidence on serious adverse events, it is still being used for APE, especially in patients with agitation and anxiety. [14,15] There is significant variation in practice with regard to clinical practice guidelines for APE. The American Heart Society and the American College of Cardiology advise against the routine administration of morphine, and only recommend morphine in patients receiving palliative care.…”

“…They included seven studies (one RCT, one non-randomised control trial and five observational studies), and 150 639 participants. Lin et al [14] studied intravenous morphine in heart failure and reviewed five studies (three propensity-matched cohorts and two retrospective analyses (one unpublished) with 14 9967 participants. Zhang et al [34] investigated the safety of morphine in patients with acute heart failure, and included seven retrospective case-control studies and 172 226 participants, including adjusted measures of effect similar to Gao et al [7] The treatment given to control groups in included studies was not described (appendix: https://www.samedical.org/file/2059 shows tables of characteristics of included and excluded studies).…”

“…However, these were not downgraded for imprecision so as to not double downgrade/penalise for both inconsistency and imprecision due to a random effects model. f. Baseline risk calculated from references Lin et al [14] and Gray et al [41] (for SAE), as these data were not provided due to the generic inverse variance methods used for meta-analysis.…”

“…Gao et al did not report their reasons for selecting the studies included in the review; neither did they report on the funding sources for each study included in the review, and hence the review was scored as moderate quality. The Lin et al [14] and Gil et al [2] reviews were of critically low quality.…”