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Gorog DA, Price S, Sibbing D, Baumbach A, Capodanno D, Gigante B, Halvorsen S, Huber K, Lettino M, Leonardi S, Morais J, Rubboli A, Siller-Matula JM, Storey RF, Vranckx P, Rocca B. Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a joint position paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:125-140. [PMID: 32049278 DOI: 10.1093/ehjcvp/pvaa009] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/10/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022]
Abstract
Timely and effective antithrombotic therapy is critical to improving outcome, including survival, in patients with acute coronary syndrome (ACS). Achieving effective platelet inhibition and anticoagulation, with minimal risk, is particularly important in high-risk ACS patients, especially those with cardiogenic shock (CS) or those successfully resuscitated following out-of-hospital cardiac arrest (OHCA), who have a 30-50% risk of death or a recurrent ischaemic event over the subsequent 30 days. There are unique challenges to achieving effective and safe antithrombotic treatment in this cohort of patients that are not encountered in most other ACS patients. This position paper focuses on patients presenting with CS or immediately post-OHCA, of presumed ischaemic aetiology, and examines issues related to thrombosis and bleeding risk. Both the physical and pharmacological impacts of CS, namely impaired drug absorption, metabolism, altered distribution and/or excretion, associated multiorgan failure, co-morbidities and co-administered treatments such as opiates, targeted temperature management, renal replacement therapy and circulatory or left ventricular assist devices, can have major impact on the effectiveness and safety of antithrombotic drugs. Careful attention to the choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring and factors that affect drug efficacy and safety, may reduce the risk of sub- or supra-therapeutic dosing and associated adverse events. This paper provides expert opinion, based on best available evidence, and consensus statements on optimising antithrombotic therapy in these very high-risk patients, in whom minimising the risk of thrombosis and bleeding is critical to improving outcome.
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Affiliation(s)
- Diana A Gorog
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Susanna Price
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Dirk Sibbing
- Ludwig-Maximilians-Universität, München, Medizinische Klinik und Poliklinik I, Campus Großhadern, München, Germany
| | - Andreas Baumbach
- Barts Heart Centre, William Harvey Research Institute, Bartshealth NHS Trust, Queen Mary University of London, West Smithfield, London, UK
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Bruna Gigante
- Unit of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science, Danderyds Hospital, Danderyd, Sweden
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Sigmund Freud University, Medical School, Vienna, Austria
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Sergio Leonardi
- Coronary Care Unit, University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Joao Morais
- Cardiology Division, Leiria Hospital Center, Pousos, Leiria, Portugal.,ciTechCare, Polytechnic of Leiria, Leiria, Portugal
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases - AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
| | | | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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Whitehead NJ, Clark AL, Williams TD, Collins NJ, Boyle AJ. Sedation and Analgesia for Cardiac Catheterisation and Coronary Intervention. Heart Lung Circ 2020; 29:169-177. [DOI: 10.1016/j.hlc.2019.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 05/05/2019] [Accepted: 08/29/2019] [Indexed: 02/01/2023]
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Holm M, Tornvall P, Henareh L, Jensen U, Golster N, Alström P, Santos-Pardo I, Witt N, Fedchenko N, Venetsanos D, Beck O, van der Linden J. The MOVEMENT Trial. J Am Heart Assoc 2020; 8:e010152. [PMID: 30636504 PMCID: PMC6497337 DOI: 10.1161/jaha.118.010152] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Morphine administration is a strong predictor of delayed onset of action of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction, likely because of impaired gastrointestinal motility. The aim of this study was to evaluate whether the peripheral opioid antagonist methylnaltrexone could improve pharmacodynamics and pharmacokinetics of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Methods and Results The MOVEMENT (Methylnaltrexone to Improve Platelet Inhibition of Ticagrelor in Morphine‐Treated Patients With ST‐Segment Elevation Myocardial Infarction) trial was a multicenter, prospective, randomized, controlled trial in patients with ST‐segment–elevation myocardial infarction treated with morphine and ticagrelor. Upon arrival to the catheterization laboratory, patients were randomized to a blinded intravenous injection of either methylnaltrexone (8 or 12 mg according to weight) or 0.9% sodium chloride. The proportion of patients with high on‐treatment platelet reactivity and plasma concentrations of ticagrelor and AR‐C124910XX were assessed at baseline (arrival in the catheterization laboratory) and 1 and 2 hours later. A total of 82 patients received either methylnaltrexone (n=43) or placebo (n=39). Median (interquartile range) time from ticagrelor administration to randomization was 41 (31–50) versus 45.5 (37–60) minutes (P=0.16). Intravenous methylnaltrexone administration did not significantly affect prevalence of high on‐treatment platelet reactivity at 2 hours after inclusion, the primary end point, when compared with placebo (54% versus 51%, P=0.84). Plasma concentrations of ticagrelor and its active metabolite, the prespecified secondary end points, did not differ significantly between the groups over time. There was no significant difference in patient self‐estimated pain between the groups. Conclusions Methylnaltrexone did not significantly improve platelet reactivity or plasma concentrations of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02942550.
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Affiliation(s)
- Manne Holm
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,2 Perioperative Medicine and Intensive Care, B31 Karolinska University Hospital Huddinge, Stockholm Sweden
| | - Per Tornvall
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Loghman Henareh
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Ulf Jensen
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nanna Golster
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Patrik Alström
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Irene Santos-Pardo
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nils Witt
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nikolai Fedchenko
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Dimitrios Venetsanos
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Olof Beck
- 5 Department of Laboratory Medicine Karolinska Institutet Stockholm Sweden
| | - Jan van der Linden
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion. Can J Cardiol 2019; 35:107-132. [PMID: 30760415 DOI: 10.1016/j.cjca.2018.11.031] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/29/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022] Open
Abstract
Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.
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Batchelor R, Liu DH, Bloom J, Noaman S, Chan W. Association of periprocedural intravenous morphine use on clinical outcomes in ST‐elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention: Systematic review and meta‐analysis. Catheter Cardiovasc Interv 2019; 96:76-88. [DOI: 10.1002/ccd.28561] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/13/2019] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Jason Bloom
- Department of CardiologyAlfred Health Melbourne Australia
| | - Samer Noaman
- Department of CardiologyAlfred Health Melbourne Australia
| | - William Chan
- Department of CardiologyAlfred Health Melbourne Australia
- Department of MedicineUniversity of Melbourne Melbourne Australia
- Department of MedicineMonash University Melbourne Australia
- Department of CardiologyWestern Health Melbourne Australia
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Rodriguez I, Philips BH, Miedel EL, Bright LA, LaTourette PC, Carty AJ, Witschey WR, Gorman RC, Gorman JH, Marx JO. Hydromorphone-induced Neurostimulation in a Yorkshire Swine ( Sus scrofa) after Myocardial Infarction Surgery. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2019; 58:601-605. [PMID: 31451134 PMCID: PMC6774467 DOI: 10.30802/aalas-jaalas-18-000095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/04/2018] [Accepted: 10/24/2018] [Indexed: 11/05/2022]
Abstract
Opiates play an important role in the control of pain associated with thoracotomy in both people and animals. However, key side effects, including sedation and respiratory depression, could limit the use of opiates in animals that are lethargic due to cardiac disease. In addition, a rare side effect-neuroexcitation resulting in pathologic behavioral changes (seizures, mania, muscle fasciculation)-after the administration of morphine or hydromorphone is well-documented in many species. In pigs, however, these drugs have been shown to stimulate an increase in normal activity. In the case presented, we describe a Yorkshire-cross pig which, after myocardial infarction surgery, went from nonresponsive to alert, responsive, and eating within 30 min of an injection of hydromorphone. This pig was not demonstrating any signs associated with pain at this time, suggesting that the positive response was due to neural stimulation. This case report is the first to describe the use of hydromorphone-a potent, pure μ opiate agonist-for its neurostimulatory effect in pigs with experimentally-induced cardiac disease.
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Affiliation(s)
| | | | - Emily L Miedel
- Department of Comparative Medicine, University of South Florida, Tampa, Florida; and
| | - Lauren A Bright
- Comparative Medicine Resources, Rutgers–The State University of New Jersey, Piscataway, New Jersey
| | - Philip C LaTourette
- University Laboratory Animal Resources
- Department of Pathobiology, School of Veterinary Medicine, and
| | | | | | - Robert C Gorman
- Surgery, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Surgery, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James O Marx
- University Laboratory Animal Resources
- Department of Pathobiology, School of Veterinary Medicine, and
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Methylnaltrexone to Reduce the Inhibitory Effects of Opioids on Drug Absorption. JACC Cardiovasc Interv 2019; 12:1550-1552. [DOI: 10.1016/j.jcin.2019.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 11/22/2022]
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Mehranfar A, Izadyar M, Shamkhali AN. Theoretical study on alkaloid encapsulating via monohydroxy-cucurbit[n]uril (n = 8,10)/graphene oxide composite. J Mol Liq 2019. [DOI: 10.1016/j.molliq.2019.111085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Koh JQS, Fernando H, Peter K, Stub D. Opioids and ST Elevation Myocardial Infarction: A Systematic Review. Heart Lung Circ 2019; 28:697-706. [DOI: 10.1016/j.hlc.2018.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/18/2018] [Accepted: 12/20/2018] [Indexed: 11/26/2022]
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Morphine and Ticagrelor Interaction in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: ATLANTIC-Morphine. Am J Cardiovasc Drugs 2019; 19:173-183. [PMID: 30353444 DOI: 10.1007/s40256-018-0305-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Morphine adversely impacts the action of oral adenosine diphosphate (ADP)-receptor blockers in ST-segment elevation myocardial infarction (STEMI) patients, and is possibly associated with differing patient characteristics. This retrospective analysis investigated whether interaction between morphine use and pre-percutaneous coronary intervention (pre-PCI) ST-segment elevation resolution in STEMI patients in the ATLANTIC study was associated with differences in patient characteristics and management. METHODS ATLANTIC was an international, multicenter, randomized study of treatment in the acute ambulance/hospital setting where STEMI patients received ticagrelor 180 mg ± morphine. Patient characteristics, cardiovascular history, risk factors, management, and outcomes were recorded. RESULTS Opioids (97.6% morphine) were used in 921 out of 1862 patients (49.5%). There were no significant differences in age, sex or cardiovascular history, but more morphine-treated patients had anterior myocardial infarction and left-main disease. Time from chest pain to electrocardiogram and ticagrelor loading was shorter with morphine (both p = 0.01) but not total ischemic time. Morphine-treated patients more frequently received glycoprotein IIb/IIIa inhibitors (p = 0.002), thromboaspiration and stent implantation (both p < 0.001). No significant difference between the two groups was found regarding pre-PCI ≥ 70% ST-segment elevation resolution, death, myocardial infarction, stroke, urgent revascularization and definitive acute stent thrombosis. More morphine-treated patients had an absence of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) 3 flow (85.8% vs. 79.7%; p = 0.001) and more had TIMI major bleeding (1.1% vs. 0.1%; p = 0.02). CONCLUSIONS Morphine-treatment was associated with increased GP IIb/IIIa inhibitor use, less pre-PCI TIMI 3 flow, and more bleeding. Judicious morphine use is advised with non-opioid analgesics preferred for non-severe acute pain. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01347580.
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Will intravenous paracetamol crush fentanyl in patients undergoing PCI for STEMI? Neth Heart J 2019; 27:169-170. [PMID: 30847664 PMCID: PMC6439103 DOI: 10.1007/s12471-019-1262-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ghadban R, Enezate T, Payne J, Allaham H, Halawa A, Fong HK, Abdullah O, Aggarwal K. The safety of morphine use in acute coronary syndrome: a meta-analysis. HEART ASIA 2019; 11:e011142. [PMID: 31031833 PMCID: PMC6454327 DOI: 10.1136/heartasia-2018-011142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/12/2019] [Accepted: 02/15/2019] [Indexed: 12/28/2022]
Abstract
Background Morphine is widely used for pain control in patients with acute coronary syndrome (ACS). Several studies have questioned the safety of morphine in this setting with a concern of interaction with and reduced efficacy of antiplatelet agents. Objective This study aims to systematically review the safety of morphine use in ACS. Methods MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were queried from inception through April 2018. Studies comparing morphine to nonmorphine use in ACS were included. Study endpoints included: in-hospital myocardial infarction (MI), all-cause mortality, stroke, major bleeding, minor bleeding and dyspnoea. Results A total of 64 323 patients with ACS were included from eight studies, seven of which were observational studies and one was a randomised controlled trial. The use of morphine was associated with increased risk of in-hospital recurrent MI (OR 1.30, 95% CI 1.18 to 1.43, p < 0.00001). There was, however, no significant difference in terms of all-cause mortality (OR 0.87, 95% CI 0.62 to 1.22, p = 0.44), stroke (OR 0.81, 95% CI 0.39 to 1.66, p = 0.57), major bleeding (OR 0.49, 95% CI 0.24 to 1.00, p = 0.05), minor bleeding (OR 0.98, 95% CI 0.41 to 2.34, p = 0.97), or dyspnoea (OR 0.55, 95% CI 0.16 to 1.83, p = 0.33). Conclusion The use of morphine for pain control in ACS was associated with an increased risk of in-hospital recurrent MI. Randomised clinical trials are needed to further investigate the safety of morphine in ACS.
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Affiliation(s)
- Rugheed Ghadban
- Division of Cardiology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Tariq Enezate
- Division of Cardiology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Joshua Payne
- Division of Cardiology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Haytham Allaham
- Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Ahmad Halawa
- Division of Cardiology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Hee Kong Fong
- Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Obai Abdullah
- Division of Cardiology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Kul Aggarwal
- Division of Cardiology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
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Duarte GS, Nunes-Ferreira A, Rodrigues FB, Pinto FJ, Ferreira JJ, Costa J, Caldeira D. Morphine in acute coronary syndrome: systematic review and meta-analysis. BMJ Open 2019; 9:e025232. [PMID: 30878985 PMCID: PMC6429865 DOI: 10.1136/bmjopen-2018-025232] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Morphine is frequently used in acute coronary syndrome (ACS) due to its analgesic effect, it being recommended in the main cardiology guidelines in Europe and the USA. However, controversy exists regarding its routine use due to potential safety concerns. We conducted a systematic review of randomised-controlled trials (RCTs) and observational studies to synthesise the available evidence. DESIGN Systematic review and meta-analysis. DATA SOURCES CENTRAL, MEDLINE, EMBASE and trial registries. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included RCTs and observational studies evaluating the impact of morphine in cardiovascular outcomes or platelet reactivity measures. DATA EXTRACTION AND SYNTHESIS Data were screened, extracted and appraised by two independent reviewers. The data were pooled results using a random-effects model. Outcomes included in-hospital mortality, major adverse cardiovascular events (MACE), platelet reactivity (using VerifyNow) and bleeding, reported as relative risk (RR) with 95% CI. We assessed the confidence in the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We followed the Meta-analysis Of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Five RCTs and 12 observational studies were included, enrolling 69 993 participants. Pooled results showed an increased risk of in-hospital mortality (RR 1.45 [95% CI 1.10 to 1.91], low GRADE confidence), MACE (RR 1.21, 95% CI 1.02 to 1.45) and an increased platelet reactivity at 1 and 2 hours (59.37 platelet reactivity units [PRU], 95% CI 36.04 to 82.71; 68.28 PRU, 95% CI 37.01 to 99.55, high GRADE confidence) associated with morphine. We found no significant difference in the risk of bleeding. We found no differences in subgroup analyses based on study design and ACS subtype. CONCLUSIONS Morphine was associated with an increased risk of in-hospital mortality and MACE but the high risk of bias leads to low result confidence. There is high confidence that morphine decreases the antiplatelet effect of P2Y12 inhibitors. PROSPERO REGISTRATION NUMBER CRD42016036357.
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Affiliation(s)
- Gonçalo Silva Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular, Lisboa, Portugal
| | - Afonso Nunes-Ferreira
- Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Filipe Brogueira Rodrigues
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular, Lisboa, Portugal
| | - Fausto J Pinto
- Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Joaquim J Ferreira
- Campus Neurológico Sénior, Torres Vedras, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Universidade de Lisboa Faculdade de Medicina, Lisboa, Portugal
| | - Joao Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Universidade de Lisboa Faculdade de Medicina, Lisboa, Portugal
- Centro de Estudos de Medicina Baseada na Evidencia, Universidade de Lisboa, Lisboa, Lisboa, Portugal
| | - Daniel Caldeira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular, Lisboa, Portugal
- Serviço de Cardiologia, Hospital Universitário de Santa Maria (CHLN), CAML, Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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Vaidya GN, Khan A, Ghafghazi S. Effect of morphine use on oral P2Y12 platelet inhibitors in acute myocardial infarction: Meta-analysis. Indian Heart J 2019; 71:126-135. [PMID: 31280824 PMCID: PMC6620420 DOI: 10.1016/j.ihj.2019.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/11/2019] [Accepted: 03/13/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Morphine is the recommended analgesic in acute myocardial infarction (AMI). This recommendation has come under scrutiny because of possible slow uptake of oral antiplatelet agents. OBJECTIVE We performed a meta-analysis of all available studies in AMI patients treated with prasugrel or ticagrelor (P2Y12 inhibitors) that reported use of morphine prior to loading the antiplatelet agents to critically assess the safety of co-administration of morphine and the newer P2Y12 inhibitors. METHODS Several sources were searched from inception to December 2017 with inclusion of eight studies, largely observational. Mean difference (MD) was calculated for continuous variables, and standardized mean difference (SMD) for platelet function was assessed by the various platelet assays, 2 h after the loading dose of oral P2Y12 inhibitors. RESULTS Higher platelet activity was noted among morphine group [SMD = 0.8, 95% confidence interval (CI) = 0.4-1.1, p < 0.01]. Morphine use caused higher odds of "high residual platelet reactivity" at 2 h (odds = 3.3, 95 %CI = 2.2-5.1, p < 0.01). Ticagrelor reached a lower plasma concentration in morphine group (MD = -481.8 ng/ml, 95% CI = -841.2 to -122.4 ng/ml, p < 0.01) with a higher vomiting rate (odds = 5.3, 95% CI = 2.5-11.1, p < 0.01). However, the composite of in-hospital mortality, stroke, and re-infarction was not significantly different between the groups (p = 0.83). CONCLUSION Co-administration of morphine with P2Y12 inhibitors possibly decreases their efficacy in platelet inhibition. However, this did not translate into higher adverse outcomes because of low event rates, inadequate for analysis. A large randomized study is needed to evaluate the narcotic-P2Y12 interaction.
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Affiliation(s)
- Gaurang Nandkishor Vaidya
- Department of Cardiovascular Medicine, University of Louisville, 201 Abraham Flexner Way, Louisville, KY 40202, USA.
| | - Abdur Khan
- Department of Cardiovascular Medicine, University of Louisville, 201 Abraham Flexner Way, Louisville, KY 40202, USA
| | - Shahab Ghafghazi
- Department of Cardiovascular Medicine, University of Louisville, 201 Abraham Flexner Way, Louisville, KY 40202, USA
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A randomised, investigator-initiated, clinical trial of the effects of fentanyl on P2Y12-receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: rationale and design of the Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial. Neth Heart J 2019; 27:185-190. [PMID: 30767166 PMCID: PMC6439041 DOI: 10.1007/s12471-019-1241-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Fast and accurate platelet inhibition is an important therapeutic goal in the acute treatment of patients with ST-elevation myocardial infarction (STEMI). Platelet inhibitory effects induced by oral P2Y12-receptor antagonists are delayed in STEMI patients undergoing primary percutaneous coronary intervention (PCI) due to haemodynamic changes and delayed gastro-intestinal absorption. Concomitant use of opioids, although recommended in the American College of Cardiology/American Heart Association and European Society of Cardiology STEMI guidelines, further delays gastro-intestinal absorption. To date, trials investigating alternative analgesics in STEMI patients have been scarce. This trial aims to assess the feasibility of a novel drug strategy for treatment of STEMI patients with crushed ticagrelor in combination with paracetamol (acetaminophen) instead of opioids. Hypothesis STEMI patients who are pre-treated with crushed ticagrelor and paracetamol have a higher level of platelet inhibition after primary PCI than patients pre-treated with crushed ticagrelor and fentanyl. Study design The Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial is a randomised controlled trial designed to examine whether administration of paracetamol instead of fentanyl can optimise platelet inhibition in STEMI patients who are pre-treated with crushed ticagrelor in the ambulance. One hundred and ninety patients with STEMI will be randomised (1:1 fashion) to intravenous (IV) fentanyl or IV paracetamol. The primary endpoint is the level of platelet reactivity units measured immediately after primary PCI. Summary The ON-TIME 3 trial (NCT03400267) aims to achieve optimal platelet inhibition and pain relief in STEMI patients receiving crushed ticagrelor in the ambulance by investigating IV fentanyl and IV paracetamol as analgesics.
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Bosson N, Isakson B, Morgan JA, Kaji AH, Uner A, Hurley K, Henry TD, Niemann JT. Safety and Effectiveness of Field Nitroglycerin in Patients with Suspected ST Elevation Myocardial Infarction. PREHOSP EMERG CARE 2019; 23:603-611. [DOI: 10.1080/10903127.2018.1558318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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A joint MD/QM study on the possibility of alkaloids detection by cucurbiturils and graphene oxide-cucurbituril composites. J Mol Liq 2018. [DOI: 10.1016/j.molliq.2018.10.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Krebs H, Perrin Bayard R, Bares A, Dahmani S, Story T, Claret PG, Bobbia X, de La Coussaye J. Délégation de l’évaluation et du traitement de la douleur à l’infirmier de Service mobile d’urgence et de réanimation : étude avant–après monocentrique. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction : La prise en charge de la douleur en médecine d’urgence préhospitalière est encore insuffisante. Cette étude a pour objectif d’évaluer les effets d’une délégation de l’évaluation et du traitement de la douleur à l’infirmier diplômé d’État (IDE) en Service mobile d’urgence et de réanimation (Smur) sur le suivi des recommandations de la Société française de médecine d’urgence (SFMU).
Méthode : Étude rétrospective de type avant–après réalisée au Smur du centre hospitalier universitaire (CHU) de Nîmes de janvier à mai 2017. Les IDE ont été formés, entre les deux phases, à un protocole de délégation de l’évaluation et du traitement de la douleur fondé sur les dernières recommandations.
Résultats : Cent quatre-vingt-un patients ont été inclus dans chaque groupe, 74 (40 %) femmes (âge moyen de 60 ± 18 ans). Les groupes étaient comparables à l’exception de la proportion d’interventions traumatologiques (11 % dans le groupe « avant » vs 20 % dans le groupe « après » ; p = 0,02). Les recommandations ont été respectées pour 12 (7 %) patients dans le groupe « avant », 21 (12 %) dans le groupe « après » (p = 0,10). Le seul facteur indépendant de respect des recommandations est le type d’intervention traumatologique (odds ratio = 9,7 ; intervalle de confiance à 95 % : [2,3–53,3] ; p < 0,01). Le nombre de patients ayant bénéficié d’une administration d’antalgique était respectivement de 55 (30 %) dans le groupe « avant » et de 73 (40 %) dans le groupe « après » (p = 0,05). La réévaluation de l’intensité douloureuse en fin de prise en charge a été consignée dans 11 (6 %) cas de la phase avant vs 38 (21 %) dans la phase après (p < 0,01). Dans le sous-groupe des patients n’ayant pas bénéficié de trinitrine, les recommandations ont été respectées respectivement pendant les phases « avant » et « après » chez 7 (6 %) patients vs 17 (14 % ; p = 0,03).
Conclusion : Malgré une augmentation du taux de prescription d’antalgiques et de réévaluation de la douleur, le protocole de délégation IDE n’a pas permis un meilleur respect des recommandations. L’établissement de protocoles spécifiques en fonction du type d’intervention, notamment traumatologique, pourrait être une piste de réflexion.
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Acute coronary syndrome (ACS) represents an umbrella of ischemic myocardial disease and diagnoses encompassing unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). UA and NSTEMI for all intents and purposes, share similar pathophysiology, but at increasing severity. This article focuses on the diagnosis, risk stratification, management, and strategies that impact outcomes in NSTEMI.
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Affiliation(s)
- Tarlan Hedayati
- Department of Emergency Medicine, John Stroger Hospital of Cook County, 1900 West Polk Street, Room 1047, Chicago, IL 60612, USA.
| | - Neha Yadav
- Cardiac Catheterization Laboratory, Division of Cardiology, John Stroger Hospital of Cook County, 1900 West Polk Street, Chicago, IL 60612, USA
| | - Jagadish Khanagavi
- Interventional Cardiology, Rush University Medical Center, 1164 West Madison Street, Apartment 718, Chicago, IL 60607, USA
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Ibrahim K, Shah R, Goli RR, Kickler TS, Clarke WA, Hasan RK, Blumenthal RS, Thiemann DR, Resar JR, Schulman SP, McEvoy JW. Fentanyl Delays the Platelet Inhibition Effects of Oral Ticagrelor: Full Report of the PACIFY Randomized Clinical Trial. Thromb Haemost 2018; 118:1409-1418. [PMID: 29972861 PMCID: PMC6202927 DOI: 10.1055/s-0038-1666862] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Morphine delays oral P2Y
12
platelet inhibitor absorption and is associated with adverse outcomes after myocardial infarction. Consequently, many physicians and first responders are now considering fentanyl as an alternative. We conducted a single-centre trial randomizing cardiac patients undergoing coronary angiography to intravenous fentanyl or not. All participants received local anaesthetic and intravenous midazolam. Those requiring percutaneous coronary intervention (PCI) with stenting received 180 mg oral ticagrelor intra-procedurally. The primary outcome was area under the ticagrelor plasma concentration–time curve (AUC
0–24 hours
). The secondary outcomes were platelet function assessed at 2 hours after loading, measured by P2Y
12
reaction units (PRUs) and light transmission platelet aggregometry. Troponin-I was measured post-PCI using a high-sensitivity troponin-I assay (hs-TnI). All participants completed a survey of pain and anxiety. Of the 212 randomized, 70 patients required coronary stenting and were loaded with ticagrelor. Two participants in the no-fentanyl arm crossed over to receive fentanyl for pain. In as-treated analyses, ticagrelor concentrations were higher in the no-fentanyl arm (AUC
0–24 hours
70% larger,
p
= 0.03). Platelets were more inhibited by 2 hours in the no-fentanyl arm (71 vs. 113 by PRU,
p
= 0.03, and 25% vs. 41% for adenosine diphosphate response by platelet aggregation,
p
< 0.01). Mean hs-TnI was higher with fentanyl at 2 hours post-PCI (11.9 vs. 7.0 ng/L,
p
= 0.04) with a rate of enzymatic myocardial infarction of 11% for fentanyl and 0% for no-fentanyl (
p
= 0.08). No statistical differences in self-reported pain or anxiety were found. In conclusion, fentanyl administration can impair ticagrelor absorption and delay platelet inhibition, resulting in mild excess of myocardial damage. This newly described drug interaction should be recognized by physicians and suggests that the interaction between opioids and oral P2Y
12
platelet inhibitors is a drug class effect associated with all opioids.
Clinical Trial Registration:
https://clinicaltrials.gov/ct2/show/NCT02683707(
NCT02683707).
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Affiliation(s)
- Khalil Ibrahim
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rohan Shah
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rakesh R Goli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Thomas S Kickler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - William A Clarke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rani K Hasan
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Roger S Blumenthal
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - David R Thiemann
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Steven P Schulman
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - John W McEvoy
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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McCarthy CP, Bhambhani V, Pomerantsev E, Wasfy JH. In-hospital outcomes in invasively managed acute myocardial infarction patients who receive morphine. J Interv Cardiol 2018; 31:150-158. [PMID: 29166703 PMCID: PMC5897161 DOI: 10.1111/joic.12464] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/13/2017] [Accepted: 10/17/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE We aimed to analyze the association between morphine and in-hospital outcomes in invasively managed ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) patients. BACKGROUND Morphine is commonly used for analgesia in the setting of acute coronary syndromes (ACS); however, recently its utility in ACS has come under closer scrutiny. METHODS We identified all STEMI and NSTE-ACS patients undergoing coronary angiogram +/- percutaneous intervention between January 2009 and July 2016 in our center and recorded patient characteristics and inpatient outcomes. RESULTS Overall, 3027 patients were examined. Overall, STEMI patients who received morphine had no difference in in-hospital mortality [4.18% vs. 7.54%, odds ratio (OR): 0.36, P = 0.19], infarct size (mean troponin level 0.75 ng/mL vs. 1.29 ng/mL, P = 0.32) or length of hospital stay (P = 0.61). The NSTE-ACS patients who received morphine had a longer hospital stay (mean 6.58 days vs. 4.78 days, P < 0.0001) and larger infarct size (mean troponin 1.16 ng/mL vs. 0.90 ng/mL, P = 0.02). Comparing matched patients, the use of morphine was associated with larger infarct size (mean troponin 1.14 ± 1.92 ng/mL vs. 0.83 ± 1.49 ng/mL, P = 0.01), longer hospital stay (6.5 ± 6.82 days vs. 4.89 ± 5.36 days, P = 0.004) and a trend towards increased mortality (5% vs. 2%, OR: 2.55, P = 0.06) in NSTE-ACS patients but morphine did not affect outcomes in the propensity matched STEMI patients. CONCLUSION In a large retrospective study, morphine was associated with larger infarct size, a longer hospital stay and a trend towards increased mortality in invasively managed NSTE-ACS patients even after adjustment for clinical characteristics.
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Affiliation(s)
- Cian P. McCarthy
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Vijeta Bhambhani
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Eugene Pomerantsev
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jason H. Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
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74
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Nakashima T, Tahara Y. Achieving the earliest possible reperfusion in patients with acute coronary syndrome: a current overview. J Intensive Care 2018; 6:20. [PMID: 29568528 PMCID: PMC5856388 DOI: 10.1186/s40560-018-0285-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 02/21/2018] [Indexed: 01/26/2023] Open
Abstract
Acute coronary syndrome (ACS) remains one of the leading causes of mortality worldwide. Appropriate management of ACS will lead to a lower incidence of cardiac arrest. Percutaneous coronary intervention (PCI) is the first-line treatment for patients with ACS. PCI techniques have become established. Thus, the establishment of a system of health care in the prehospital and emergency department settings is needed to reduce mortality in patients with ACS. In this review, evidence on how to achieve earlier diagnosis, therapeutic intervention, and decision to reperfuse with a focus on the prehospital and emergency department settings is systematically summarized. The purpose of this review is to generate current, evidence-based consensus on scientific and treatment recommendations for health care providers who are the initial points of contact for patients with signs and symptoms suggestive of ACS.
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Affiliation(s)
- Takahiro Nakashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565 Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565 Japan
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Bartko J, Schoergenhofer C, Schwameis M, Wadowski P, Kubica J, Jilma B, Hobl EL. Morphine Interaction with Aspirin: a Double-Blind, Crossover Trial in Healthy Volunteers. J Pharmacol Exp Ther 2018. [PMID: 29540563 DOI: 10.1124/jpet.117.247213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aspirin is a cornerstone in the antiplatelet therapy for acute coronary syndromes. Coadministration of morphine may potentially influence the intestinal absorption, pharmacokinetics, and pharmacodynamics, as seen with P2Y12 inhibitors. In this trial, healthy volunteers were randomized to receive morphine (5 mg, i.v. bolus injection) at one of seven different time points before, after, or with aspirin (162 mg, p.o.) in a double-blind, placebo-controlled fashion. After a 14-day washout, subjects received placebo instead of morphine. Pharmacokinetics were determined by liquid chromatography, and aspirin's effects were measured by platelet function tests (whole-blood platelet aggregation: multiplate, platelet plug formation: PFA-100). Morphine increased the total acetylsalicylic acid exposure by 20% compared with placebo when given simultaneously with aspirin, whereas Cmax and tmax were not altered. Morphine had no significant effect on aspirin-induced platelet inhibition. In contrast to coadministration with P2Y12 inhibitors, morphine appears to have negligible interaction with aspirin.
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Affiliation(s)
- Johann Bartko
- Department of Clinical Pharmacology, Medical University of Vienna (J.B., C.S., M.S., P.W., B.J., E.-L.H.), and Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Centre Meidling (J.B.), Vienna, Austria; and Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J.K.)
| | - Christian Schoergenhofer
- Department of Clinical Pharmacology, Medical University of Vienna (J.B., C.S., M.S., P.W., B.J., E.-L.H.), and Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Centre Meidling (J.B.), Vienna, Austria; and Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J.K.)
| | - Michael Schwameis
- Department of Clinical Pharmacology, Medical University of Vienna (J.B., C.S., M.S., P.W., B.J., E.-L.H.), and Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Centre Meidling (J.B.), Vienna, Austria; and Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J.K.)
| | - Patricia Wadowski
- Department of Clinical Pharmacology, Medical University of Vienna (J.B., C.S., M.S., P.W., B.J., E.-L.H.), and Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Centre Meidling (J.B.), Vienna, Austria; and Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J.K.)
| | - Jacek Kubica
- Department of Clinical Pharmacology, Medical University of Vienna (J.B., C.S., M.S., P.W., B.J., E.-L.H.), and Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Centre Meidling (J.B.), Vienna, Austria; and Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J.K.)
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna (J.B., C.S., M.S., P.W., B.J., E.-L.H.), and Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Centre Meidling (J.B.), Vienna, Austria; and Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J.K.)
| | - Eva-Luise Hobl
- Department of Clinical Pharmacology, Medical University of Vienna (J.B., C.S., M.S., P.W., B.J., E.-L.H.), and Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Centre Meidling (J.B.), Vienna, Austria; and Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland (J.K.)
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Bonin M, Mewton N, Roubille F, Morel O, Cayla G, Angoulvant D, Elbaz M, Claeys MJ, Garcia-Dorado D, Giraud C, Rioufol G, Jossan C, Ovize M, Guerin P. Effect and Safety of Morphine Use in Acute Anterior ST-Segment Elevation Myocardial Infarction. J Am Heart Assoc 2018; 7:JAHA.117.006833. [PMID: 29440010 PMCID: PMC5850179 DOI: 10.1161/jaha.117.006833] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Morphine is commonly used to treat chest pain during myocardial infarction, but its effect on cardiovascular outcome has never been directly evaluated. The aim of this study was to examine the effect and safety of morphine in patients with acute anterior ST‐segment elevation myocardial infarction followed up for 1 year. Methods and Results We used the database of the CIRCUS (Does Cyclosporine Improve Outcome in ST Elevation Myocardial Infarction Patients) trial, which included 969 patients with anterior ST‐segment elevation myocardial infarction, admitted for primary percutaneous coronary intervention. Two groups were defined according to use of morphine preceding coronary angiography. The composite primary outcome was the combined incidence of major adverse cardiovascular events, including cardiovascular death, heart failure, cardiogenic shock, myocardial infarction, unstable angina, and stroke during 1 year. A total of 554 (57.1%) patients received morphine at first medical contact. Both groups, with and without morphine treatment, were comparable with respect to demographic and periprocedural characteristics. There was no significant difference in major adverse cardiovascular events between patients who received morphine compared with those who did not (26.2% versus 22.0%, respectively; P=0.15). The all‐cause mortality was 5.3% in the morphine group versus 5.8% in the no‐morphine group (P=0.89). There was no difference between groups in infarct size as assessed by the creatine kinase peak after primary percutaneous coronary intervention (4023±118 versus 3903±149 IU/L; P=0.52). Conclusions In anterior ST‐segment elevation myocardial infarction patients treated by primary percutaneous coronary intervention, morphine was used in half of patients during initial management and was not associated with a significant increase in major adverse cardiovascular events at 1 year.
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Affiliation(s)
- Mickael Bonin
- Unité d'hémodynamique et Cardio-Vasculaire Interventionnel, Institut du Thorax, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
| | - Nathan Mewton
- Centre d'Investigations Cliniques, Service d'explorations Fonctionnelles Cardiovasculaires, Hôpital Cardiologique Louis Pradel, Bron, France
| | - Francois Roubille
- UFR de Médecine, Cardiology Department, Hôpital Arnaud-de-Villeneuve, CHU Montpellier, University of Montpellier 1, Montpellier, France
| | - Olivier Morel
- Cardiology Department, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
| | - Guillaume Cayla
- Cardiology Department, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Denis Angoulvant
- Cardiology Department and EA4245, Faculté de Médecine, Tours University Hospital, University François-Rabelais, Tours, France
| | - Meyer Elbaz
- Cardiology Department, Rangueil Hospital, Toulouse, France
| | - Marc J Claeys
- Cardiology Department, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | | | - Céline Giraud
- Centre d'Investigations Cliniques, Service d'explorations Fonctionnelles Cardiovasculaires, Hôpital Cardiologique Louis Pradel, Bron, France
| | - Gilles Rioufol
- Interventional Cardiology Department, Hospices Civils de Lyon, Lyon, France
| | - Claire Jossan
- Centre d'Investigations Cliniques, Service d'explorations Fonctionnelles Cardiovasculaires, Hôpital Cardiologique Louis Pradel, Bron, France
| | - Michel Ovize
- Centre d'Investigations Cliniques, Service d'explorations Fonctionnelles Cardiovasculaires, Hôpital Cardiologique Louis Pradel, Bron, France
| | - Patrice Guerin
- Unité d'hémodynamique et Cardio-Vasculaire Interventionnel, Institut du Thorax, Centre Hospitalier Universitaire (CHU) Nantes, Nantes, France
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77
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Schenone AL, Chen K, Andress K, Militello M, Cho L. Editor’s Choice- Sedation in the coronary intensive care unit: An adapted algorithm for critically ill cardiovascular patient. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:167-175. [DOI: 10.1177/2048872617753797] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the current era, cardiovascular intensive care units care for more complex patients who are far sicker than historical post-myocardial infarction patients, and sedation has become a common intervention in these units. Current sedation best practices derive mainly from non-cardiac units which limits their generalization to the critically ill cardiac patient. Thus, a great variability in sedation protocols, especially the selection of sedative agents, is commonly seen in daily practice across cardiac units. We present an updated review on sedation in cardiovascular critical care medicine with emphasis on the hemodynamic impact. The goal of this review is to generate a general sedation algorithm specific for the cardiac patient.
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Affiliation(s)
- AL Schenone
- Department of Cardiovascular Medicine, Cleveland Clinic, USA
| | - K Chen
- Internal Medicine Department, Cleveland Clinic, USA
| | - K Andress
- Internal Medicine Department, Cleveland Clinic, USA
| | | | - L Cho
- Department of Cardiovascular Medicine, Cleveland Clinic, USA
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78
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Barańska M, Sikora A, Buszko K, Siemińska E, Marszałł MP, Siller-Matula J, Jilma B, Alexopoulos D, Fabiszak T, Kubica J, Niezgoda P, Sikora J. Crushed sublingual versus oral ticagrelor administration strategies in patients with unstable angina. Thromb Haemost 2017; 117:718-726. [DOI: 10.1160/th16-08-0670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/31/2016] [Indexed: 11/05/2022]
Abstract
SummaryOral administration of crushed ticagrelor tablets turned out to be an efficacious method that improves its pharmacokinetics and pharmacodynamics. This strategy, however, is unlikely to eliminate the drug-drug interaction in patients receiving intravenous morphine, as the impairment of the P2Y12 inhibitor absorption related to decreased propulsive motility of the gastro-intestinal tract is the most likely mechanism of interaction. Thus, we designed a pharmacokinetic and pharmacodynamic study setting the feasibility of platelet inhibition with a loading dose of ticagrelor given as crushed tablets sublingually compared with two other ticagrelor loading dose administration strategies: integral tablet given orally and crushed tablet given orally in patients with unstable angina. Ticagrelor and its metabolite AR-C124900XX plasma concentration was evaluated in nine time points (time frame of 6 hours) using liquid chromatography coupled with mass spectrometry; platelet reactivity was evaluated using multiple electrode aggregometry. The area under the plasma concentration-time curve for ticagrelor and AR-C124900XX was significantly higher in patients treated with crushed tablets given orally compared with crushed tablets given sublingually only within the first hour after loading dose (936.9 ± 898.0 vs 368.0 ± 422.4, p=0.042 and 103.4 ± 120.8 vs 31.3 ± 43.9, p=0.031, respectively). Moreover, we showed significantly stronger platelet inhibition in patients receiving crushed ticagrelor orally vs. sublingually at 30 and 45 min after the loading dose (p=0.024 and p=0.016, respectively). Therefore, the administration strategy of ticagrelor determines the pharmacokinetic and pharmacodynamic profile of both ticagrelor and its active metabolite AR-C124900XX.
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Giannopoulos G, Deftereos S, Kolokathis F, Xanthopoulou I, Lekakis J, Alexopoulos D. P2Y12 Receptor Antagonists and Morphine: A Dangerous Liaison? Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.116.004229. [PMID: 27586412 DOI: 10.1161/circinterventions.116.004229] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
P2Y12 receptor antagonists, concurrently administered with aspirin in what has come to be commonly called dual antiplatelet therapy, are a mainstay of treatment for patients with acute coronary syndromes. Morphine, on the contrary, is a commonly used drug in the acute phase of acute coronary syndromes to relieve pain-with the added potential benefit of attenuating acutely raised sympathetic tone. In current guidelines, though, morphine is recommended with decreasing strength of recommendation. One reason is that it raises concern regarding the potentially significant interaction with antiplatelet agents, leading to impaired inhibition of platelet activation. In any case, it is still considered a mandatory part of the inventory of available medications in prehospital acute myocardial infarction management. The goal of the present review is to present published evidence on morphine and its potential interactions with P2Y12 receptor antagonists, as well as on the central issue of whether such interactions may underlie clinically significant effects on patient outcomes.
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Affiliation(s)
- Georgios Giannopoulos
- From the Second Department of Cardiology, National and Kapodistrean University of Athens, Attikon University Hospital, Greece (G.G., S.D., F.K., J.L., D.A.); and Department of Cardiology, University of Patras, University Hospital of Rio, Greece (I.X.).
| | - Spyridon Deftereos
- From the Second Department of Cardiology, National and Kapodistrean University of Athens, Attikon University Hospital, Greece (G.G., S.D., F.K., J.L., D.A.); and Department of Cardiology, University of Patras, University Hospital of Rio, Greece (I.X.)
| | - Fotios Kolokathis
- From the Second Department of Cardiology, National and Kapodistrean University of Athens, Attikon University Hospital, Greece (G.G., S.D., F.K., J.L., D.A.); and Department of Cardiology, University of Patras, University Hospital of Rio, Greece (I.X.)
| | - Ioanna Xanthopoulou
- From the Second Department of Cardiology, National and Kapodistrean University of Athens, Attikon University Hospital, Greece (G.G., S.D., F.K., J.L., D.A.); and Department of Cardiology, University of Patras, University Hospital of Rio, Greece (I.X.)
| | - John Lekakis
- From the Second Department of Cardiology, National and Kapodistrean University of Athens, Attikon University Hospital, Greece (G.G., S.D., F.K., J.L., D.A.); and Department of Cardiology, University of Patras, University Hospital of Rio, Greece (I.X.)
| | - Dimitrios Alexopoulos
- From the Second Department of Cardiology, National and Kapodistrean University of Athens, Attikon University Hospital, Greece (G.G., S.D., F.K., J.L., D.A.); and Department of Cardiology, University of Patras, University Hospital of Rio, Greece (I.X.)
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Promes SB, Glauser JM, Smith MD, Torbati SS, Brown MD. Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction. Ann Emerg Med 2017; 70:724-739. [PMID: 29056206 DOI: 10.1016/j.annemergmed.2017.09.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Adamski P, Sikora J, Laskowska E, Buszko K, Ostrowska M, Umińska JM, Sikora A, Skibińska N, Sobczak P, Adamska U, Rość D, Kubica A, Paciorek P, Marszałł MP, Navarese EP, Gorog DA, Kubica J. Comparison of bioavailability and antiplatelet action of ticagrelor in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction: A prospective, observational, single-centre study. PLoS One 2017; 12:e0186013. [PMID: 29023473 PMCID: PMC5638327 DOI: 10.1371/journal.pone.0186013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/22/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Data from available studies suggest that the presence of ST-elevation myocardial infarction (STEMI) may be associated with delayed and attenuated ticagrelor bioavailability and effect compared with non-ST-elevation myocardial infarction (NSTEMI). METHODS In a single-center, prospective, observational trial 73 patients with myocardial infarction (STEMI n = 49, NSTEMI n = 24) underwent a pharmacokinetic and pharmacodynamic assessment after a 180 mg ticagrelor loading dose (LD). Ticagrelor and its active metabolite (AR-C124910XX) plasma concentrations were determined with liquid chromatography tandem mass spectrometry, and their antiplatelet effect was measured with the VASP assay and multiple electrode aggregometry. RESULTS During the first six hours after ticagrelor LD, STEMI patients had 38% and 34% lower plasma concentration of ticagrelor and AR-C124910XX, respectively, than NSTEMI (ticagrelor AUC(0-6): 2491 [344-5587] vs. 3991 [1406-9284] ng*h/mL; p = 0.038; AR-C124910XX AUC(0-6): 473 [0-924] vs. 712 [346-1616] ng*h/mL; p = 0.027). STEMI patients also required more time to achieve maximal concentration of ticagrelor (tmax: 4.0 [3.0-12.0] vs. 2.5 [2.0-6.0] h; p = 0.012). Impaired bioavailability of ticagrelor and AR-C124910XX seen in STEMI subjects was associated with diminished platelet inhibition in this group, which was most pronounced during the initial hours of treatment. CONCLUSIONS Plasma concentrations of ticagrelor and AR-C124910XX during the first hours after ticagrelor LD were one third lower in STEMI than in NSTEMI patients. This reduced and delayed ticagrelor bioavailability was associated with weaker antiplatelet effect in STEMI. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02602444 (November 09, 2015).
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Affiliation(s)
- Piotr Adamski
- Department of Principles of Clinical Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- * E-mail:
| | - Joanna Sikora
- Department of Pharmacology and Therapy, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Ewa Laskowska
- Department of Principles of Clinical Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Katarzyna Buszko
- Department of Theoretical Foundations of Biomedical Science and Medical Informatics, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Principles of Clinical Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Julia M. Umińska
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Adam Sikora
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Natalia Skibińska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Przemysław Sobczak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Urszula Adamska
- Chair of Dermatology, Sexually Transmitted Diseases and Immunodermatology, Faculty of Medicine, Nicolaus Copernicus University in Toruń, Poland
| | - Danuta Rość
- Department of Pathophysiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Przemysław Paciorek
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michał P. Marszałł
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Diana A. Gorog
- National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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McCarthy CP, Donnellan E, Wasfy JH, Bhatt DL, McEvoy JW. Time-honored treatments for the initial management of acute coronary syndromes: Challenging the status quo. Trends Cardiovasc Med 2017; 27:483-491. [DOI: 10.1016/j.tcm.2017.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 04/27/2017] [Accepted: 05/02/2017] [Indexed: 11/16/2022]
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Ferreira J. Vascular phenotypes of acute decompensated vs. new-onset heart failure: treatment implications. ESC Heart Fail 2017; 4:679-685. [PMID: 28960929 PMCID: PMC5695185 DOI: 10.1002/ehf2.12210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/20/2017] [Accepted: 08/09/2017] [Indexed: 12/28/2022] Open
Abstract
Aims Acute heart failure (HF) is a frequent and life‐threatening syndrome with heterogeneous clinical, haemodynamic, and neurohormonal features. This article describes the vascular phenotypes associated with acute decompensated chronic HF (ADCHF), and new‐onset acute HF (NOAHF). Data Synthesis Worsening of chronic HF occurs with full activation of adaptive mechanisms that maintain blood pressure (BP) and systemic perfusion. Rapid onset of HF in the setting of previous normal functioning heart not only does not allow full activation of adaptive mechanisms but also generates inappropriate responses from systemic endothelium leading to low BP/hypotension. Consequently, the treatment of ADCHF is based on diuretics and vasodilators, while in NOAHF, vasoconstrictors may be required to maintain BP to allow the correction of the acute cardiac disease. Conclusions Patients with ADCHF and NOAHF present different vascular phenotypes with treatment implications.
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Affiliation(s)
- Jorge Ferreira
- Department of Cardiology, Hospital Santa Cruz, CHLO, Av Prof Reynaldo Santos, 2790-134, Carnaxide, Portugal
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85
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Agarwal M, Agrawal S, Garg L, Mohananey D, Garg A, Bhatia N, Lavie CJ. National Trends in the Incidence, Management, and Outcomes of Heart Failure Complications in Patients Hospitalized for ST-Segment Elevation Myocardial Infarction. Mayo Clin Proc Innov Qual Outcomes 2017; 1:26-36. [PMID: 30225399 PMCID: PMC6135030 DOI: 10.1016/j.mayocpiqo.2017.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To analyze contemporary trends in the incidence, management, and clinical outcomes of heart failure (HF) complications in patients hospitalized for ST-segment elevation myocardial infarction (STEMI) in the United States. Patients and Methods Using the 2003 through 2010 Nationwide Inpatient Sample databases, all patients with STEMI who were 18 years and older with acute HF were identified. Overall trends in the incidence of HF, coronary intervention, and in-hospital mortality were analyzed. Results Of 1,990,002 hospitalizations with a primary diagnosis of STEMI, 471,525 (23.7%) had HF complication (decreasing from 25.4% [95% CI, 25.3%-25.6%] in 2003 to 20.7% [95% CI, 20.5%-20.8%]) in 2010 (P trend<.001). The incidence of cardiogenic shock in patients with HF-complicated STEMI increased from 13.9% (95% CI, 13.6%-14.1%) to 22.6% (95% CI, 22.2%-23.0%) during this period (P trend<.001). From 2003 through 2010, the use of diagnostic coronary angiography and percutaneous coronary intervention increased in patients with HF-complicated STEMI from 44.3% to 62.1% and from 25.0% to 48.1%, respectively. In-hospital mortality decreased significantly in patients with HF-complicated STEMI (from 18.1% to 15.1%) and in subgroups of those with (from 42.4% to 29.9%) and without (from 14.1% to 10.8%) cardiogenic shock (all P trend<.001). The adjusted odds ratio (AOR) (per year) of death was 0.992 (95% CI, 0.988-0.997; P<.001), which changed significantly after additional adjustment for coronary intervention (AOR [per year], 1.012; 95% CI, 1.008-1.017; P<.001). Conclusion The incidence and in-hospital mortality of HF-complicated STEMI has decreased significantly during recent times along with increased use of percutaneous coronary intervention and diagnostic coronary angiography.
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Key Words
- ACE, angiotensin-converting enzyme
- AMI, acute myocardial infarction
- AOR, adjusted odds ratio
- CABG, coronary artery bypass graft
- CPI, consumer price index
- CV, cardiovascular
- HF, heart failure
- ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- IQR, interquartile range
- LOS, length of stay
- NIS, Nationwide Inpatient Sample
- NRMI-2, National Registry of Myocardial Infarction-2
- OR, odds ratio
- PCI, percutaneous coronary intervention
- STEMI, ST-segment elevation myocardial infarction
- UOR, unadjusted odds ratio
- dCA, diagnostic coronary angiography
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Affiliation(s)
- Manyoo Agarwal
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis
| | - Sahil Agrawal
- Division of Cardiovascular Medicine, Department of Internal Medicine, St Luke’s University Health Network, Bethlehem, PA
| | - Lohit Garg
- Division of Cardiovascular Medicine, Department of Internal Medicine, Lehigh Valley Network Hospital, Allentown, PA
| | | | - Aakash Garg
- Department of Internal Medicine, Saint Peter's Health, New Brunswick, NJ
| | - Nirmanmoh Bhatia
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt Medical Center, Nashville, TN
| | - Carl J. Lavie
- Department of Cardiovascular Medicine, John Ochsner Heart and Vascular Institute, Ochsner Clinical School–The University of Queensland School of Medicine, New Orleans, LA
- Correspondence: Address to Carl J. Lavie, MD, John Ochsner Heart and Vascular Institute, Ochsner Clinical School–The University of Queensland School of Medicine, 1514 Jefferson Hwy, New Orleans, LA 70121-2483.
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Chauhan V, Shah PK, Galwankar S, Sammon M, Hosad P, Beeresha, Erickson TB, Gaieski DF, Grover J, Hegde AV, Hoek TV, Jarwani B, Kataria H, LaBresh KA, Manjunath CN, Nagamani AC, Patel A, Patel K, Ramesh D, Rangaraj R, Shamanur N, Sridhar L, Srinivasa KH, Tyagi S. The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India. J Emerg Trauma Shock 2017; 10:74-81. [PMID: 28367012 PMCID: PMC5357871 DOI: 10.4103/jets.jets_148_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India.
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Affiliation(s)
- Vivek Chauhan
- Department of Emergency Medicine, Dr. RPGMC, Kangra, Himachal Pradesh, India
| | | | - Sagar Galwankar
- Department of Emergency Medicine, University of Florida, Jacksonville, FL, USA
| | - Maura Sammon
- Department of Emergency Medicine, School of Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Prabhakar Hosad
- Chief Intervention Cardiologist, Father Muller Medical College Hospital, Mangalore, Karnataka, India
| | - Beeresha
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Timothy B Erickson
- Department of Emergency Medicine, Brigham and Women's Hospital, Medical School Harvard, Humanitarian Initiative, Boston, USA
| | - David F Gaieski
- Department of Emergency Medicine, Jefferson University, Philadelphia, USA
| | - Joydeep Grover
- Department of Emergency Medicine, Southmead Hospital, Bristol, UK
| | - Anupama V Hegde
- Department of Cardiology, M. S. Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India
| | - Terry Vanden Hoek
- Department of Emergency Medicine, University of Illinois, Illinois, USA
| | - Bhavesh Jarwani
- Department of Emergency Medicine, VS General Hospital, Smt. NHLM Medical College, Ahmedabad, Gujarat, India
| | - Himanshu Kataria
- Department of Emergency Medicine, Whiston Hospital, St. Helens and Knowsley Teaching Hospital Trust, Prescot, UK
| | - Kenneth A LaBresh
- Cardiology, Emeritus, RTI International, 61 Skyline Dr Hinsdale, MA, USA
| | | | - A C Nagamani
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Anjali Patel
- Department of Emergency Medicine, Zydus Hospital, Ahmedabad, Gujarat, India
| | - Ketan Patel
- Department of Emergency Medicine, Zydus Hospital, Ahmedabad, Gujarat, India
| | - D Ramesh
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - R Rangaraj
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Narendra Shamanur
- Department of Emergency Medicine, SSIMS and RC, Davangere, Karnataka, India
| | - L Sridhar
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - K H Srinivasa
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Shweta Tyagi
- Deapartment of Emergency Medicine, Sir H. N. Reliance Foundation Hospital, Mumbai, Maharashtra, India
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Matthews R, McCaul M, Smith W. A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town. Afr J Emerg Med 2017; 7:24-29. [PMID: 30456102 PMCID: PMC6234150 DOI: 10.1016/j.afjem.2017.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 10/21/2016] [Accepted: 01/10/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa. METHODS A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider. RESULTS A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4). DISCUSSION Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.
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Affiliation(s)
- Ryan Matthews
- Cape Peninsula University of Technology, Department of Emergency Medical Care, PO Box 1906, Bellville 7535, South Africa
| | - Michael McCaul
- Stellenbosch University, Centre for Evidence-based Health Care (CEBHC), PO Box 241, Cape Town 800, South Africa
| | - Wayne Smith
- University of Cape Town, Division of Emergency Medicine and Provincial Government of the Western Cape, Private Bag x24, Bellville 7535, South Africa
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Gunnarsson SI, Mitchell J, Busch MS, Larson B, Gharacholou SM, Li Z, Raval AN. Outcomes of Physician-Staffed Versus Non-Physician-Staffed Helicopter Transport for ST-Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.116.004936. [PMID: 28154162 PMCID: PMC5523778 DOI: 10.1161/jaha.116.004936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The effect of physician‐staffed helicopter emergency medical service (HEMS) on ST‐elevation myocardial infarction (STEMI) patient transfer is unknown. The purpose of this study was to evaluate the characteristics and outcomes of physician‐staffed HEMS (Physician‐HEMS) versus non‐physician‐staffed (Standard‐HEMS) in patients with STEMI. Methods and Results We studied 398 STEMI patients transferred by either Physician‐HEMS (n=327) or Standard‐HEMS (n=71) for primary or rescue percutaneous coronary intervention at 2 hospitals between 2006 and 2014. Data were collected from electronic medical records and each institution's contribution to the National Cardiovascular Data Registry. Baseline characteristics were similar between groups. Median electrocardiogram‐to‐balloon time was longer for the Standard‐HEMS group than for the Physician‐HEMS group (118 vs 107 minutes; P=0.002). The Standard‐HEMS group was more likely than the Physician‐HEMS group to receive nitroglycerin (37% vs 15%; P<0.001) and opioid analgesics (42.3% vs 21.7%; P<0.001) during transport. In‐hospital adverse outcomes, including cardiac arrest, cardiogenic shock, and serious arrhythmias, were more common in the Standard‐HEMS group (25.4% vs 11.3%; P=0.002). After adjusting for age, sex, Killip class, and transport time, patients transferred by Standard‐HEMS had increased risk of any serious in‐hospital adverse event (odds ratio=2.91; 95% CI=1.39–6.06; P=0.004). In‐hospital mortality was not statistically different between the 2 groups (9.9% in the Standard‐HEMS group vs 4.9% in the Physician‐HEMS group; P=0.104). Conclusions Patients with STEMI transported by Standard‐HEMS had longer transport times, higher rates of nitroglycerin and opioid administration, and higher rates of adjusted in‐hospital events. Efforts to better understand optimal transport strategies in STEMI patients are needed.
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Affiliation(s)
- Sverrir I Gunnarsson
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - Joseph Mitchell
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - Mary S Busch
- Mayo Clinic Health System-Franciscan Healthcare, La Crosse, WI
| | - Brenda Larson
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
| | - S Michael Gharacholou
- Mayo Clinic Health System-Franciscan Healthcare, La Crosse, WI.,Division of Cardiology, Mayo Clinic, Rochester, MN
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI
| | - Amish N Raval
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI
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Holm M, Tornvall P, Westerberg J, Rihan Hye S, van der Linden J. Ticagrelor pharmacokinetics and pharmacodynamics in patients with NSTEMI after a 180-mg loading dose. Platelets 2017; 28:706-711. [PMID: 28150519 DOI: 10.1080/09537104.2016.1265921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The pharmacokinetics after a 180-mg loading dose (LD) of ticagrelor has not been thoroughly investigated in NSTEMI patients. We aimed to compare the ticagrelor uptake and on-treatment platelet reactivity between non-ST-segment elevation myocardial infarction (NSTEMI) patients and a control group of patients with stable coronary artery disease (SCAD) undergoing elective percutaneous coronary intervention. We performed an observational, prospective, single-center study including 40 NSTEMI patients and 20 SCAD controls. Key exclusion criteria included ongoing opioid treatment. Both groups received a 180-mg ticagrelor LD, and blood samples were taken pre-dose and 1, 2, 3, 4, 5, and 6 hours post-LD. Plasma concentrations of ticagrelor and its active metabolite AR-C124910XX were determined by validated methods. Platelet aggregation was tested using ADP-induced multiple electrode aggregometry. The primary endpoint was the time to maximal ticagrelor concentration (Tmax). Clinical trial registration identifier number: NCT02292277. None of the pharmacokinetic variables differed significantly between the groups, including the Tmax of ticagrelor (2.0h [1.0-3.0] versus 2.0h [2.0-3.0], p = 0.393) and the active metabolite AR-C124910XX (3.0 [2.0-4.0] versus 3.0 [2.5-4.0], p = 0.289). High on-treatment platelet reactivity (HPR) was defined as > 46 aggregation units and was at one hour seen in 15% of the NSTEMI patients versus 10% of the controls (p = 1.0). At two hours post the 180-mg ticagrelor LD, 3% of the NSTEMI patients had HPR compared with none of the controls (p = 1.0). In conclusion, the uptake of ticagrelor was not significantly slower in NSTEMI patients not receiving opioids compared with the SCAD controls, leading to adequate onset of platelet inhibition in both groups.
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Affiliation(s)
- Manne Holm
- a Department of Cardiothoracic Surgery and Anesthesiology , Karolinska University Hospital, Stockholm, Sweden.,b Department of Molecular Medicine and Surgery , Karolinska Institutet, Stockholm, Sweden
| | - Per Tornvall
- c Department of Science and Education, Södersjukhuset (Stockholm South General Hospital) , Karolinska Institutet , Stockholm , Sweden
| | - Julia Westerberg
- a Department of Cardiothoracic Surgery and Anesthesiology , Karolinska University Hospital, Stockholm, Sweden
| | - Shaym Rihan Hye
- a Department of Cardiothoracic Surgery and Anesthesiology , Karolinska University Hospital, Stockholm, Sweden
| | - Jan van der Linden
- a Department of Cardiothoracic Surgery and Anesthesiology , Karolinska University Hospital, Stockholm, Sweden.,b Department of Molecular Medicine and Surgery , Karolinska Institutet, Stockholm, Sweden
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Crea F, Binder RK, Lüscher TF. The year in cardiology 2016: acute coronary syndromes. Eur Heart J 2017; 38:154-164. [PMID: 28043974 DOI: 10.1093/eurheartj/ehw620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/02/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Institute of Cardiology, Catholic University, Largo A. Gemelli, 800168 Rome, Italy
| | - Ronald K Binder
- Department of Cardiology, University Heart Center, University Hospital Zurich, Raemstrasse 100, 8091 Zurich, Switzerland
| | - Thomas F Lüscher
- Department of Cardiology, University Heart Center, University Hospital Zurich, Raemstrasse 100, 8091 Zurich, Switzerland
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Morphine Does Not Affect Myocardial Salvage in ST-Segment Elevation Myocardial Infarction. PLoS One 2017; 12:e0170115. [PMID: 28081269 PMCID: PMC5231339 DOI: 10.1371/journal.pone.0170115] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 12/29/2016] [Indexed: 11/28/2022] Open
Abstract
Recent studies have proposed intravenous (IV) morphine is associated with delayed action of antiplatelet agents in acute myocardial infarction. However, it is unknown whether morphine results in increased myocardial damage in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We investigated myocardial salvage index (MSI) to determine whether IV morphine affects myocardial injury adversely in STEMI patients undergoing primary PCI. 299 STEMI patients underwent contrast-enhanced magnetic resonance imaging a median of 3 days after PCI. Infarct size was measured on delayed-enhancement imaging, and area at risk was quantified on T2-weighted imaging. MSI was calculated as ‘[area at risk–infarct size] X 100 / area at risk’. IV morphine was administrated in 32.1% of patients. Patients treated with morphine had shorter symptom to balloon time and higher prevalence of Thrombolysis in Myocardial Infarction flow grade 0 or 1. The morphine group showed a trend toward larger MSI and infarct size and significantly greater area at risk than the non-morphine group. After propensity score matching (90 pairs), MSI was similar between the morphine and non-morphine group (46.1% versus 43.5%, P = .11), and infarct size and area at risk showed no difference. In propensity score-matched analysis, IV morphine prior to primary PCI in STEMI patients did not cause adverse impacts on myocardial salvage.
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92
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Spinetti G, Madeddu P. The Peter Principle in Cardiovascular Cell Therapy: The Decline of a Theory or the Theory of a Decline. Circ Res 2016; 119:1283-1285. [PMID: 27932473 DOI: 10.1161/circresaha.116.310017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gaia Spinetti
- From the IRCCS MultiMedica, Milan, Italy (G.S.); and Bristol Heart Institute, University of Bristol, United Kingdom (P.M.)
| | - Paolo Madeddu
- From the IRCCS MultiMedica, Milan, Italy (G.S.); and Bristol Heart Institute, University of Bristol, United Kingdom (P.M.).
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93
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Flierl U, Zauner F, Sieweke JT, Berliner C, Napp LC, Tillmanns J, Bauersachs J, Schäfer A. Efficacy of prasugrel administration immediately after percutaneous coronary intervention in ST-elevation myocardial infarction. Thromb Haemost 2016; 117:99-104. [PMID: 27734075 DOI: 10.1160/th16-07-0569] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/17/2016] [Indexed: 11/05/2022]
Abstract
Prasugrel, a potent thienopyridine, achieves stronger inhibition of platelet activation than clopidogrel. However, onset of inhibition is significantly delayed in patients with acute ST-elevation myocardial infarction (STEMI), as haemodynamic instability and morphine application seem to exhibit significant influence. Since rapid onset of effect was demonstrated in non-STEMI patients when prasugrel was administered only after percutaneous coronary intervention (PCI) without increasing cardiovascular event rates we assessed the efficacy of prasugrel loading immediately after PCI for STEMI instead of pre-loading before revascularisation. We investigated 50 consecutive patients with acute STEMI (mean age 56 ± 10 years) admitted for primary PCI. Prasugrel efficacy was assessed by platelet reactivity index (PRI; VASP assay) before, 1, 2, 4, 6, 12, and 24 hours following an oral loading dose of 60 mg immediately after PCI. High on-treatment platelet reactivity (HTPR) was defined as PRI>50 %. Prasugrel significantly and rapidly reduced platelet reactivity in acute STEMI patients (p<0.0001 at each time point vs control). Morphine application resulted in a significantly higher HTPR rate among patients having received morphine less than 1 hour before prasugrel loading (p<0.001) while concomitant metoclopramide (MCP) treatment did not significantly affect prasugrel efficacy. In conclusion, in contrast to previous reports describing a significant delay in onset of prasugrel-mediated P2Y12 inhibition in acute STEMI, we observed a rapid onset with low HTPR rates comparable to those observed in stable non-STEMI patients. Prasugrel administered directly after primary PCI might therefore be a useful therapeutic strategy in patients with STEMI to provide strong and effective P2Y12 inhibition.
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Affiliation(s)
| | | | | | | | | | | | | | - Andreas Schäfer
- Prof. Dr. Andreas Schäfer, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany, Tel.: +49 511 532 5240, Fax: +49 511 532 8244, E-mail:
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94
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Adamski P, Adamska U, Ostrowska M, Koziński M, Kubica J. New directions for pharmacotherapy in the treatment of acute coronary syndrome. Expert Opin Pharmacother 2016; 17:2291-2306. [PMID: 27677394 DOI: 10.1080/14656566.2016.1241234] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Acute coronary syndromes (ACS) are one of the leading causes of death worldwide. Several landmark trials, followed by a widespread introduction of new agents, have significantly improved ACS outcomes in recent years. However, despite the use of contemporary therapy, a substantial number of ACS patients continue to suffer from cardiovascular events. Areas covered: The aim of this review was to summarize available data on innovative drugs and pharmacological strategies that have potential to amend the current ACS therapy. We present the results of recent large clinical trials, as well as insights from ongoing phase III and phase IV studies, exploring the value of new strategies for the improvement of outcomes in ACS. Expert opinion: More potent platelet inhibition, more profound lipid reduction and possibly anti-inflammatory action are considered to have potential to further reduce the rates of adverse cardiovascular and thrombotic events in ACS patients. 'Hit fast, hit hard' approach regarding novel antiplatelet and lipid-lowering therapy seems attractive, but it has to be considered that these strategies may be associated with increased adverse events rate. Introduction of cangrelor and ezetimibe, and potentially future recognition of proprotein convertase subtilisin/kexin type 9 antibodies, are likely to alter the landscape of ACS pharmacotherapy.
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Affiliation(s)
- Piotr Adamski
- a Department of Principles of Clinical Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Urszula Adamska
- b Department of Dermatology, Sexually Transmitted Diseases and Immunodermatology, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Małgorzata Ostrowska
- a Department of Principles of Clinical Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Marek Koziński
- a Department of Principles of Clinical Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Jacek Kubica
- c Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
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95
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McCarthy CP, McEvoy JW. The narrative review on morphine in acute coronary syndrome: Recognizing opioidergic cardioprotection-reply. Am Heart J 2016; 180:e7-8. [PMID: 27659894 DOI: 10.1016/j.ahj.2016.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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96
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Morphine use and myocardial reperfusion in patients with acute myocardial infarction treated with primary PCI. Int J Cardiol 2016; 221:567-71. [DOI: 10.1016/j.ijcard.2016.06.204] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/17/2016] [Accepted: 06/25/2016] [Indexed: 01/23/2023]
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97
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Maslov LN, Khaliulin I, Oeltgen PR, Naryzhnaya NV, Pei J, Brown SA, Lishmanov YB, Downey JM. Prospects for Creation of Cardioprotective and Antiarrhythmic Drugs Based on Opioid Receptor Agonists. Med Res Rev 2016; 36:871-923. [PMID: 27197922 PMCID: PMC5082499 DOI: 10.1002/med.21395] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 12/19/2022]
Abstract
It has now been demonstrated that the μ, δ1 , δ2 , and κ1 opioid receptor (OR) agonists represent the most promising group of opioids for the creation of drugs enhancing cardiac tolerance to the detrimental effects of ischemia/reperfusion (I/R). Opioids are able to prevent necrosis and apoptosis of cardiomyocytes during I/R and improve cardiac contractility in the reperfusion period. The OR agonists exert an infarct-reducing effect with prophylactic administration and prevent reperfusion-induced cardiomyocyte death when ischemic injury of heart has already occurred; that is, opioids can mimic preconditioning and postconditioning phenomena. Furthermore, opioids are also effective in preventing ischemia-induced arrhythmias.
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Affiliation(s)
| | - Igor Khaliulin
- School of Clinical SciencesUniversity of BristolBristolUK
| | | | | | - Jian‐Ming Pei
- Department of PhysiologyFourth Military Medical UniversityXi'anP. R. China
| | | | - Yury B. Lishmanov
- Research Institute for CardiologyTomskRussia
- National Research Tomsk Polytechnic University634050TomskRussia
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98
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Khan N, Cox AR, Cotton JM. Pharmacokinetics and pharmacodynamics of oral P2Y12 inhibitors during the acute phase of a myocardial infarction: A systematic review. Thromb Res 2016; 143:141-8. [DOI: 10.1016/j.thromres.2016.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/11/2016] [Accepted: 05/18/2016] [Indexed: 12/23/2022]
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99
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McCarthy CP, Mullins KV, Sidhu SS, Schulman SP, McEvoy JW. The on- and off-target effects of morphine in acute coronary syndrome: A narrative review. Am Heart J 2016; 176:114-21. [PMID: 27264228 DOI: 10.1016/j.ahj.2016.04.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/12/2016] [Indexed: 12/31/2022]
Abstract
With potent analgesic properties, perceived hemodynamic benefits and limited alternatives, morphine is the analgesic mainstay for patients with nitrate resistant chest pain due to acute Myocardial Infarction (MI). However, observational data suggest that morphine administration during MI may have negative consequences. While vomiting, hypotension and respiratory depression are established side effects, recent reports have demonstrated attenuated and delayed oral anti-platelet agent absorption, as well as suboptimal reperfusion after MI, all of which may translate into adverse cardiovascular outcomes. These data have resulted in reduced support for morphine in recent European and U.S. clinical practice guidelines for MI; despite the absence of any prospective randomized outcomes trials addressing this question. As such, randomized trials are now necessary to confirm whether or not morphine, which is administered in up to 30% of MI cases, causes adverse clinical outcomes in these patients. However, given that placebo-controlled randomized trial designs evaluating morphine in MI are limited by an ethical requirement for appropriate analgesia, alternative investigational approaches may be necessary. In this article we review the updated evidence for morphine in MI and outline novel strategies that may facilitate future investigation of this clinical dilemma.
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100
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Kaliyadan AG, Savage MP, Ruggiero N, Fischman DL. An update on management of the patient presenting with non-ST-elevation acute coronary syndromes. Hosp Pract (1995) 2016; 44:173-8. [PMID: 27098650 DOI: 10.1080/21548331.2016.1179119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over 780,000 patients in the United States are diagnosed with an acute coronary syndrome (ACS) each year. As physicians, it is our responsibility to provide prompt workup, diagnosis and management of these patients. After identification of the patient with ACS and confirming there is not ST-segment elevation MI requiring immediate revascularization, physicians should pursue a work-up for non-ST-elevation acute coronary syndrome (NSTE-ACS). It is important to understand the latest best practice guidelines in the treatment and management of patients with NSTE-ACS who carry high rates of in-hospital mortality. Physicians must integrate the clinical history and examination, electrocardiogram and laboratory findings in order to properly diagnose an NSTE-ACS. Early treatment with guideline directed medical therapy is imperative even in the setting of an early invasive strategy with cardiac catheterization and percutaneous coronary intervention. The focus of this review is to discuss the appropriate strategies for evaluation and management of patients with NSTE-ACS based on the most recent ACC/AHA practice guidelines.
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Affiliation(s)
- Antony G Kaliyadan
- a Division of Cardiology , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Michael P Savage
- a Division of Cardiology , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Nicholas Ruggiero
- a Division of Cardiology , Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - David L Fischman
- a Division of Cardiology , Thomas Jefferson University Hospital , Philadelphia , PA , USA
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