Morphine, Oxygen, Nitrates, and Mortality Reducing Pharmacological Treatment for Acute Coronary Syndrome: An Evidence-based Review

Abstract

Since it was first reported in 1912, acute coronary syndrome (ACS) has become the leading cause of death in the Western world. Several improvements that have been made over the years in the pharmacological treatment of ACS have reduced the relative risk of death due to myocardial infarction from 35-45% previously to approximately 3.5% at present. Universities, websites, and educational videos commonly use a mnemonic for morphine, oxygen, nitrates, and aspirin (MONA) to refer to the adjuvant treatment used for the management of ACS.We review the scientific data pertaining to treatment strategies for the management of ACS and discuss whether MONA remains relevant in the present scenario.While using morphine and oxygen is associated with risks such as higher mortality and increase in the size of the infarct, respectively, several available drugs such as fibrinolytics, anticoagulants, beta-blockers, renin-angiotensin-aldosterone system inhibitors, P2Y12 inhibitors, and statins are known to be useful to treat ACS.MONA should be viewed as an obsolete teaching and learning aid, and therefore we recommend that its use be discontinued for the management of ACS.

Oxygen therapy practices in the acutely ill medical patients: A social media-based nationwide study of clinicians’ preferences and summary of current recommendations

“…Nowadays, there are concerns that this approach might be obsolete and inappropriate. 25 A similar approach, warranting high SaO 2 targets, was also evident in the current survey for patients in the early period post-cardiac arrest.…”

Cardioprotective Effect of Isosorbide Dinitrate Postconditioning Against Rat Myocardial Ischemia-Reperfusion Injury In Vivo

“…Nitrates are exogenous donors of NO that have been used for more than 130 years history and are among the most widely used anti-myocardial ischemia drugs. Several clinical trials demonstrated that nitrates reduce infarct size in combination with thrombolytic therapy, but most results were negative and even indicated reverse outcomes [16,17]. In addition, there is no published experimental or clinical study focused on nitrate postconditioning.…”

Opioids in clinical practice

“…A number of studies have noted an increased mortality risk in heart failure patients receiving morphine [35][36][37]. Morphine provides analgesic benefits in patients with myocardial infarction, and it decreases blood pressure and anterior brachial mean pressure in these patients.…”