Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study

Abstract

Background: Studies have shown disparate results on the consequences of morphine use in ST-segment elevation myocardial infarction (STEMI). No study has evaluated alternative treatments that could be at least non-inferior to morphine without its potentially damaging consequences for myocardial function and platelet reactivity. The aim of this study was to evaluate whether nitrous oxide/oxygen plus intravenous acetaminophen (NOO-A) is non-inferior to morphine to control chest pain in STEMI patients. Methods: This multicenter, open-label, cluster-randomized, controlled, non-inferiority study compared NOO-A with morphine in 684 prehospital patients with ongoing suspected STEMI of < 12 h duration and a pain rating score ≥ 4. The primary endpoint was the proportion of patients achieving pain relief (numeric rating score ≤ 3) after 30 min. Secondary safety endpoints included serious adverse events and death at 30 days. Results: The median baseline pain score was 7.0 in both groups. The primary endpoint occurred in 51.7% of the NOO-A group and 73.6% of the morphine group (absolute risk difference − 21.7%; 95% confidence interval − 29.6 to − 13.8). At 30 days, the rate of serious adverse events was 16.0 and 18.8% in the NOO-A and morphine groups respectively (p = NS). The rate of death was 1.8% (NOO-A group) and 3.8% (morphine group) (p = NS). Conclusion: Analgesia provided by NOO-A was inferior to morphine at 30 min in patients with acute STEMI in the prehospital setting. Rates of serious adverse events did not differ between groups. Trial registration: ClinicalTrials.gov: NCT02198378.

Differential impact of fentanyl and morphine doses on ticagrelor-induced platelet inhibition in ST-segment elevation myocardial infarction: a subgroup analysis from the PERSEUS randomized trial

“…Our study suggests that when intravenous opioids are needed to relieve acute pain in symptomatic STEMI patients who were pre-treated with ticagrelor, the use of lower, instead of higher, doses of fentanyl may accelerate ticagrelor absorption and achieve faster platelet inhibition compared to the use of morphine. These findings may be of relevant clinical interest given the lack of effective therapeutic alternatives to intravenous opioids for pain relief in the management of STEMI ( 16 , 37 ). However, considering the post-hoc and non-prespecified design of the present study and the small number of patients included, these results are hypothesis-generating and a larger-scale dedicated randomized trial is needed to confirm our findings.…”

Propuesta de manejo inicial del infarto de miocardio con elevación del segmento ST no complicado en centros sin capacidad de intervención coronaria percutánea en el Perú

“…Uso de atorvastatina 40 -80mg o rosuvastatina 20-40 mg tan pronto como sea posible. Administradas de forma temprana en el contexto de IMCEST han demostrado mejorar el flujo sanguíneo en la ARI, disminuir el daño por isquemia/ reperfusión y, por ende, el tamaño del infarto (44)(45)(46) .…”