Prehospital opioid dose and myocardial injury in patients with ST elevation myocardial infarction

Abstract

ObjectiveTo characterise the relationship between opioid dose and myocardial infarct size in patients with ST elevation myocardial infarction (STEMI).MethodsPatients given opioid treatment by emergency medical services with confirmed STEMI were included in this secondary, retrospective cohort analysis of the Air versus Oxygen in Myocardial Infarction (AVOID) study. Patients with cardiogenic shock were excluded. The primary endpoint was comparison of cardiac biomarkers as a measure of infarct size based on opioid dose (low ≤8.75 mg, intermediate 8.76–15 mg and high >15 mg of intravenous morphine equivalent dose).Results422 patients were included in the analysis. There was a significantly higher proportion of patients with Thrombolysis in Myocardial Infarction (TIMI) 0 or 1 flow pre-percutaneous coronary intervention (PCI) (94% vs 81%, p=0.005) and greater use of thrombus aspiration catheters (59% vs 30%, p<0.001) in the high compared with low-dose opioid group. After adjustment for potential confounders, every 1 mg of intravenous morphine equivalent dose was associated with a 1.4% (95% CI 0.2%, 2.7%, p=0.028) increase in peak creatine kinase; however, this was no longer significant after adjustment for TIMI flow pre-PCI.ConclusionsOur study suggests no benefit of higher opioid dose and a dose-dependent signal between opioid dose and increased myocardial infarct size. Prospective randomised controlled trials are required to establish causality given that this may also be explained by patients with a greater ischaemic burden requiring higher opioid doses due to more severe pain. Future research also needs to focus on strategies to mitigate the opioid–P2Y12 inhibitor interaction and non-opioid analgesia to treat ischaemic chest pain.

Sex differences in prehospital analgesia in patients presenting with acute coronary syndromes and their association with clinical outcomes

“…| 991 based on cardiac biomarkers, as well as higher rates of TIMI 0 or 1 flow pre-PCI in patients administered high-dose opioids; however, the sample size was too small to assess clinical endpoints. 7 Although preprocedural TIMI 0-2 flow has been demonstrated as an independent predictor of mortality, it should be noted that in the present study, we did not see an increased risk of 30-day MACE or MACCE in male or female patients administered opioids. 21 Prior studies evaluating the impact of opioids on clinical outcomes have shown mixed results.…”

“…Suggesting that opioids may play a role in early P2Y 12 treatment failure 20 . A prior study from our group demonstrated an association between opioid dose and infarct size based on cardiac biomarkers, as well as higher rates of TIMI 0 or 1 flow pre‐PCI in patients administered high‐dose opioids; however, the sample size was too small to assess clinical endpoints 7 …”

Association between pre-hospital chest pain severity and myocardial injury in ST elevation myocardial infarction: A post-hoc analysis of the AVOID study

“…This exacerbates the delayed onset of platelet inhibition seen in patients with ST elevation myocardial infarction where therapeutic inhibition may only occur 4 or more hours after oral loading of P2Y 12 inhibitors [21] , [22] , [23] . Retrospective studies have suggested that administration of higher opioid doses may be associated with poorer outcomes although prospective randomized trials are required to confirm these findings as results are conflicting [3] , [24] , [25] , [26] , [27] .…”

ANalgesic Efficacy and safety of MOrphiNe versus methoxyflurane in patients with acute myocardial infarction: the rationale and design of the ANEMON-SIRIO 3 study: a multicentre, open-label, phase II, randomised clinical trial

“…The concept to apply methoxyflurane in patients with ACS is supported by recently published results of the AVOID study. 27 The reported incidence of no-reflow phenomenon after PCI in patients with STEMI was higher in the high-dose compared with low-dose opioid group. Moreover, higher doses of opioids were associated with greater infarct size.…”

“…Moreover, higher doses of opioids were associated with greater infarct size. 27 …”