Morphine in the Setting of Acute Heart Failure: Do the Risks Outweigh the Benefits?

Abstract

The use of opioids in acute pulmonary oedema is considered standard therapy by many physicians. The immediate relieving effect of morphine on the key symptomatic discomfort associated with acute heart failure, dyspnoea, facilitated the categorisation of morphine as a beneficial treatment in this setting. During the last decade, several retrospective studies raised concerns regarding the safety and efficacy of morphine in the setting of acute heart failure. In this article, the physiological effects of morphine on the cardiovascular and respiratory systems are summarised, as well as the potential clinical benefits and risks associated with morphine therapy. Finally, the reported clinical outcomes and adverse event profiles from recent observational studies are discussed, as well as future perspectives and potential alternatives to morphine in the setting of acute heart failure.

The safety of morphine in patients with acute heart failure: A systematic review and meta‐analysis

“…It is worth noting that propensity score matching inevitably greatly reduced the sample size. As Caspi et al 31 mentioned before, propensity score matching has loose generalizability and precision, with potentially numerous unmeasured confounding variables. More importantly, the difference in physical status between the two groups significantly influenced the results of the study, especially in patients with AHF.…”

Morphine in acute pulmonary oedema: a signal of harm but more questions than answers

“…However, randomized controlled trials have not provided persuasive evidence of clinical benefit for its use in patients with APO 8 . Morphine‐induced reduction in venous tone may be considered advantageous in the setting of APO, as it may result in a volume shift from central to peripheral venous circulation but may also lead to decreased cardiac output and hypotension 9 …”

“…In addition, morphine use is associated with other adverse effects, such as reduction in both hypoxic and hypercapnic respiratory drive, decrease of mental awareness, as well as nausea and vomiting with potential risk of aspiration, particularly in APO patients requiring treatment with continuous positive airway pressure 8,9 …”

“…peripheral venous circulation but may also lead to decreased cardiac output and hypotension. 9 In addition, morphine use is associated with other adverse effects, such as reduction in both hypoxic and hypercapnic respiratory drive, decrease of mental awareness, as well as nausea and vomiting with potential risk of aspiration, particularly in APO patients requiring treatment with continuous positive airway pressure. 8,9 In patients with acute coronary syndrome (ACS), morphine may be used to reduce pain, dyspnoea or anxiety, but it attenuates platelet inhibition because of slower absorption, delayed onset of action, and reduced bioavailability of oral anti-platelet agents.…”

“…9 In addition, morphine use is associated with other adverse effects, such as reduction in both hypoxic and hypercapnic respiratory drive, decrease of mental awareness, as well as nausea and vomiting with potential risk of aspiration, particularly in APO patients requiring treatment with continuous positive airway pressure. 8,9 In patients with acute coronary syndrome (ACS), morphine may be used to reduce pain, dyspnoea or anxiety, but it attenuates platelet inhibition because of slower absorption, delayed onset of action, and reduced bioavailability of oral anti-platelet agents. 10,11 This is particularly relevant in cardiogenic shock where, beyond its vasodilatory effects, morphine causes splanchnic hypoperfusion with further delay of gastric motility and decreased bioavailability of all oral drugs.…”