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Möckel M. The new ESC acute coronary syndrome guideline and its impact in the CPU and emergency department setting. Herz 2024; 49:185-189. [PMID: 38467788 DOI: 10.1007/s00059-024-05241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/13/2024]
Abstract
The new guideline on acute coronary syndrome (ACS) of the European Society of Cardiology (ESC) replaces two separate guidelines on ST-elevation myocardial infarction (STEMI) and non-ST-elevation (NSTE) ACS. This change of paradigm reflects the experts view that the ACS is a continuum, starting with unstable angina and ending in cardiogenic shock or cardiac arrest due to severe myocardial ischemia. Secondary, partly non-atherosclerotic-caused myocardial infarctions ("type 2") are not integrated in this concept.With respect to acute care in the setting of emergency medicine and the chest pain unit structures, the following new aspects have to be taken into account:1. New procedural approach as "think A.C.S." meaning "abnormal ECG," "clinical context," and "stable patient"2. New recommendation regarding a holistic approach for frail patients3. Revised recommendations regarding imaging and timing of invasive strategy in suspected NSTE-ACS4. Revised recommendations for antiplatelet and anticoagulant therapy in STEMI5. Revised recommendations for cardiac arrest and out-of-hospital cardiac arrest6. Revised recommendations for in-hospital management (starting in the CPU/ED) and ACS comorbid conditionsIn summary, the changes are mostly gradual and are not based on extensive new evidence, but more on focused and healthcare process-related considerations.
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Affiliation(s)
- Martin Möckel
- Notfall- und Akutmedizin mit Chest Pain Units, Charité-Universitätsmedizin Berlin, Campus Mitte und Virchow-Klinikum, Charitéplatz 1, 10117, Berlin, Germany.
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Spagnolo M, Angiolillo DJ, Capodanno D. Evaluating the pharmacokinetic and pharmacodynamic impact of different modes of ticagrelor administration. Expert Opin Drug Metab Toxicol 2023; 19:769-784. [PMID: 37849294 DOI: 10.1080/17425255.2023.2272595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Alternative administration modes for oral P2Y12 inhibitors, particularly ticagrelor, have emerged as a potential alternative to overcome the limitations associated with the delayed onset of action of these drugs in patients who are unable to swallow or with impaired absorption. AREAS COVERED This comprehensive literature review aims to provide an overview of the current state of knowledge on the pharmacokinetics and administration modes of ticagrelor, including factors that may affect its action. It also compares the pharmacokinetics of ticagrelor with that of other drugs with similar uses to provide a comprehensive understanding of the potential advantages and limitations of different modalities of P2Y12 administration. For this purpose, Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from database inception to July 2023. EXPERT OPINION Among the different alternatives, crushed formulations, especially for ticagrelor, have emerged as the most promising option, showing early and robust platelet inhibition. However, important questions remain unanswered, such as the comparative clinical benefits of crushed ticagrelor versus standard administration, the cost-effectiveness of alternative modes compared to intravenous P2Y12 inhibitors such as cangrelor, and the important limitations associated with the concomitant use of opioids, who have been proven to impair even the action of crushed ticagrelor.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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Lee SW, Kuo N, Hou SK, Kang YN. Effects of morphine and P2Y inhibitor amongst patients with acute coronary syndrome: A meta-analysis of comparative studies. Am J Emerg Med 2023; 70:119-126. [PMID: 37270851 DOI: 10.1016/j.ajem.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND P2Y inhibitor and morphine are widely used in caring for patients with the acute coronary syndrome (ACS), but there are some concerns about the combination use due to interaction in metabolism. Therefore, this study aimed to examine whether using morphine with antiplatelets in patients with ACS affects the clinical outcomes based on currently available evidence. METHODS Three databases were searched for comparative studies on this topic by using relevant keywords of ACS and morphine. Two authors independently extracted study information, mortality, major adverse cardiac event (MACE), major bleeding, and length of hospital stay. Then, they evaluated the quality of evidence independently. Meta-analysis was planned to be conducted in random-effects model. Risk ratio (RR) was used for most outcomes except hospital stay, and Peto odds ratio (POR) was used if there were any zero cells. Pooled estimate was presented with 95% confidence interval (CI). RESULTS Fourteen studies (n = 73,033) met eligibility criteria, and there was non-significant difference in mortality between antiplatelet with and without morphine (RR = 1.13, 95%CI: 0.78 to 1.64). Antiplatelet therapy without morphine significantly reduced the risk of MACE (RR = 0.78, 95%CI: 0.67 to 0.89; I-square = 0%), but increased the odds of major bleeding (POR = 1.87, 95%CI: 1.04 to 3.35; I-square = 0%) as compared with the combined use of antiplatelet therapy and morphine. CONCLUSION In conclusion, there is no statistically significant difference in mortality in patients with ACS using morphine or not, but clinicians ought to make a trade-off between a lower risk of MACE and a higher risk of major bleeding before adding morphine to antiplatelet therapy.
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Affiliation(s)
- Suh-Won Lee
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ning Kuo
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Yi-No Kang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Institute of Health Policy & Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Connolly M, Ryder M. Consideration of Symptom Management in Advanced Heart Failure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15160. [PMID: 36429877 PMCID: PMC9690631 DOI: 10.3390/ijerph192215160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 06/16/2023]
Abstract
This work provides an opinion on palliative care for people with heart disease. The work focuses on the management of key symptoms associated with both end stage heart disease, applying a palliative approach and suggesting treatment options. The work also indicates the potential for greater collaboration of specialist teams including specialist palliative care in the assessment and management of patients with complex needs as they progress through their disease trajectory. The practical application of evidence-based guidelines and recommendations is key to the successful individualised management of complex symptoms.
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Affiliation(s)
- Michael Connolly
- School of Nursing, Midwifery & Health Systems, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Education & Research Centre, Our Lady’s Hospice & Care Services, Harold’s Cross, D6W RY72 Dublin, Ireland
| | - Mary Ryder
- School of Nursing, Midwifery & Health Systems, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
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Fabris E, Selvarajah A, Tavenier A, Hermanides R, Kedhi E, Sinagra G, van’t Hof A. Complementary Pharmacotherapy for STEMI Undergoing Primary PCI: An Evidence-Based Clinical Approach. Am J Cardiovasc Drugs 2022; 22:463-474. [PMID: 35316483 PMCID: PMC9468081 DOI: 10.1007/s40256-022-00531-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
Antithrombotic therapy is the cornerstone of pharmacological treatment in patients undergoing primary percutaneous coronary intervention (PCI). However, the acute management of ST elevation myocardial infarction (STEMI) patients includes therapy for pain relief and potential additional strategies for cardioprotection. The safety and efficacy of some commonly used treatments have been questioned by recent evidence. Indeed a concern about morphine use is the interaction between opioids and oral P2Y12 inhibitors; early beta-blocker treatment has shown conflicting results for the improvement of clinical outcomes; and supplemental oxygen therapy lacks benefit in patients without hypoxia and may be of potential harm. Other additional strategies remain disappointing; however, some treatments may be selectively used. Therefore, we intend to present a critical updated review of complementary pharmacotherapy for a modern treatment approach for STEMI patients undergoing primary PCI.
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Impact of periprocedural morphine use on mortality in STEMI patients treated with primary PCI. PLoS One 2021; 16:e0245433. [PMID: 33439911 PMCID: PMC7806148 DOI: 10.1371/journal.pone.0245433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intravenous morphine (MO) decreases the effect of all oral platelet P2Y12 receptor inhibitors in vitro and observational reports suggest that its use may be associated with larger infarct size. Yet, there are limited data available about the impact of this interaction on clinical outcomes. We studied the effect of MO on mortality in ST-segment elevation myocardial infarction (STEMI) patients treated with primary PCI using a prospective registry. METHODS Of the 1255 patients who underwent primary PCI, 397 received MO based on physician's judgment. Clopidogrel was used as P2Y12 receptor antagonist in all cases. Median follow-up time was 7.5 years with 457 deaths. To adjust for confounding, two propensity score-based procedures were performed: 1 to 1 matching (PSM, 728 cases), and inverse probability of treatment weighting (IPTW) retaining data from all patients. Primary outcome measure was time to all-cause death, whereas predischarge left ventricular ejection fraction (LVEF) was used as secondary end point. RESULTS An adequate balance on baseline covariates was achieved by both methods. We found no difference in survival as the HR (MO/no MO) was 0.98 (95% confidence interval [CI]: 0.76-1.26), p = 0.86 using PSM and 1.01 (95% CI: 0.84-1.23), p = 0.88 with IPTW. Likewise, distributions of LVEFs were similar using either methods: with PSM, median LVEFs were 50.0% (interquartile range [IQR]: 43.0%-55.3%) vs 50.0% (IQR: 42.0%-55.0%) in the no MO and MO groups, respectively (p = 0.76), whereas using IPTW, they were 50.0% (IQR: 42.5%-55.0%) vs 50.0% (IQR: 41.0%-55.0%), respectively (p = 0.86). CONCLUSIONS Our data suggest that morphine use may have no impact on long-term mortality and on predischarge ejection fraction in STEMI patients treated with primary PCI.
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Moore CH, Lukas JG, Cave BE, Khouzam RN. Challenges of Combining Opioids and P2Y 12 Inhibitors in Acute Coronary Syndrome: Should the Future Be Opioid Free? Curr Probl Cardiol 2020; 46:100781. [PMID: 33453543 DOI: 10.1016/j.cpcardiol.2020.100781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
Morphine has been long recognized as standard of care in the treatment of acute coronary syndrome (ACS) patients; however, its safety has recently been called into question due to a drug interaction with P2Y12 inhibitors. Opioids, given in combination with P2Y12 inhibitors, can reduce antiplatelet effects by slowing gastrointestinal motility and ultimately reducing drug absorption. While there are proposed benefits of opioids in ACS patients, conflicting data regarding clinical outcomes exist. The majority of clinical data slightly favors opioid use in ST-elevation myocardial infarction over non-ST-elevation myocardial infarction, although trends for increased myocardial infarction are present in both settings. Current practice should be aimed at discerning the need for routine opioid use in ACS. Alternative strategies may be needed to overcome these interactions; however, no robust data are currently available to support these treatment options. Future research should be aimed at non-opioid treatment options in ACS, as opioid use remains controversial in this population.
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Affiliation(s)
- Catherine H Moore
- Department of Pharmacy, Methodist University Hospital, Memphis, TN; Department of Clinical and Translational Science, University of Tennessee Health Sciences Center, Memphis, TN.
| | - Jack G Lukas
- Department of Pharmacy, Methodist University Hospital, Memphis, TN
| | - Brandon E Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN; Department of Clinical and Translational Science, University of Tennessee Health Sciences Center, Memphis, TN
| | - Rami N Khouzam
- Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Sciences Center, Methodist Le Bonheur Healthcare System, Memphis, TN
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Effects of morphine on P2Y 12 platelet inhibitors in patients with acute myocardial infarction: A meta-analysis. Am J Emerg Med 2020; 41:219-228. [PMID: 33317866 DOI: 10.1016/j.ajem.2020.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/31/2020] [Accepted: 11/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To explore the effects of morphine on P2Y12 platelet inhibitors in patients with acute myocardial infarction (AMI). METHODS PubMed, Embase, Cochrane Library, and Web of Science were used to retrieve literature through 11th May 2019. Standardized weighted mean difference (SMD) and relative risk (RR) with 95% confidence intervals (CI), P-value, and I2 value were used to assess the strength of the association in this meta-analysis. Outcomes included platelet reactivity, high residual platelet reactivity (HRPR), ticagrelor maximum concentration (Cmax), ticagrelor area under curve (AUC), death rate, reinfarction rate, stroke, stent thrombosis, thrombolysis in myocardial infarction (TIMI) hemorrhage, dyspnea, emesis, contrast-induced nephropathy, and pulmonary edema. RESULTS A total of 13 articles were included in this study, containing 5688 patients (morphine group: n = 2014, control group: n = 3674). Results illustrated that the morphine group had a higher platelet reactivity (SMD: 0.834, 95%CI: 0.483-1.186, P < 0.001) and HRPR rate (RR: 1.994, 95%CI: 1.536-2.588, P < 0.001) than the control group, while the Cmax of ticagrelor (WMD: -481.838, 95%CI: -841.242-122.434, P = 0.009) was lower than that of the control group. The death rate of the morphine group was lower than that in the control group (RR: 0.561, 95%CI: 0.337-0.933, P = 0.026). The morphine group had a higher emesis rate than the control group (RR: 4.486, 95%CI: 2.263-8.891, P < 0.001). CONCLUSION Morphine effectively suppresses the inhibition effect of P2Y12 platelet inhibitors in patients with AMI.
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Tavenier AH, Hermanides RS, Fabris E, Angiolillo DJ, van 't Hof AWJ. Bridging the gap: Current and future insights for improving suboptimal platelet inhibition in STEMI. Int J Cardiol 2020; 328:40-45. [PMID: 33242504 DOI: 10.1016/j.ijcard.2020.11.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/31/2020] [Accepted: 11/17/2020] [Indexed: 01/31/2023]
Abstract
Antiplatelet therapy is one of the cornerstones in the acute treatment of patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI). However, hemodynamic changes and delayed intestinal absorption of P2Y12 inhibitors leads to a delay in the onset of antiplatelet effects resulting in a gap of platelet inhibition. Several strategies have been proposed to bridge this gap, such as pre-hospital administration of antiplatelet therapy, higher loading doses of P2Y12 inhibitors, crushing or chewing tablets, subcutaneous or intravenous administration of platelet inhibitors, or use of pain relievers alternative to opioids that do not delay intestinal absorption of oral platelet inhibitors. These strategies may improve platelet inhibition with the goal of optimizing clinical outcomes in the acute phase of STEMI. In this review we present current and future insights for bridging the gap in platelet inhibition in STEMI patients undergoing primary PCI.
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Affiliation(s)
| | | | - Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Arnoud W J van 't Hof
- Department of Cardiology, Isala, Zwolle, the Netherlands; Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
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Tavenier AH, Hermanides RS, Ottervanger JP, Tolsma R, van Beurden A, Slingerland RJ, ter Horst PGJ, Gosselink ATM, Dambrink JHE, van Leeuwen MAH, Roolvink V, Kedhi E, Klungel OH, Belitser SV, Angiolillo DJ, Pustjens T, Rasoul S, Gho B, Stein M, Ruiters L, van ‘t Hof AWJ. Impact of opioids on P2Y12 receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:4-12. [PMID: 32730628 PMCID: PMC8728016 DOI: 10.1093/ehjcvp/pvaa095] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/19/2020] [Accepted: 07/23/2020] [Indexed: 01/09/2023]
Abstract
Aims Platelet inhibition induced by P2Y12 receptor antagonists in patients with ST-elevation myocardial infarction (STEMI) can be affected by concomitant use of opioids. The aim of this trial was to examine the effect of intravenous (iv) acetaminophen compared with iv fentanyl on P2Y12 receptor inhibition in patients with STEMI. Methods and results The Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial randomized 195 STEMI patients who were scheduled to undergo primary percutaneous coronary intervention (PCI) and were pre-treated with crushed ticagrelor to iv acetaminophen (N = 98) or iv fentanyl (N = 97) in the ambulance. The primary endpoint, consisting of the level of platelet reactivity units (PRU) measured immediately after primary PCI, was not significantly different between the study arms [median PRU 104 (IQR 37–215) vs. 175 (63–228), P = 0.18]. However, systemic levels of ticagrelor were significantly higher in the acetaminophen arm at the start of primary PCI [151 ng/mL (32–509) vs. 60 ng/mL (13–206), P = 0.007], immediately after primary PCI [326 ng/mL (94–791) vs. 115 ng/mL (38–326), P = 0.002], and at 1 h after primary PCI [488 ng/mL (281–974) vs. 372 ng/mL (95–635), P = 0.002]. Acetaminophen resulted in the same extent of pain relief when compared with fentanyl [reduction of 3 points on 10-step-pain scale before primary PCI (IQR 1–5)] in both study arms (P = 0.67) and immediately after PCI [reduction of 5 points (3–7); P = 0.96]. Conclusion The iv acetaminophen in comparison with iv fentanyl was not associated with significantly lower platelet reactivity in STEMI patients but resulted in significantly higher ticagrelor plasma levels and was effective in pain relief.
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Affiliation(s)
| | - Renicus S Hermanides
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Rudolf Tolsma
- Ambulancedienst IJsselland, Voltastraat 3-A, 8013 PM Zwolle, The Netherlands
| | | | | | | | - A T Marcel Gosselink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Jan-Henk E Dambrink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Maarten A H van Leeuwen
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Vincent Roolvink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Elvin Kedhi
- Department of Cardiology, AZ Sint-Jan, Brugge, Belgium
| | - Olaf H Klungel
- Department of Pharmacoepidemiology, University of Utrecht, Utrecht, The Netherlands
| | - Svetlana V Belitser
- Department of Pharmacoepidemiology, University of Utrecht, Utrecht, The Netherlands
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Tobias Pustjens
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Saman Rasoul
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Ben Gho
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Mera Stein
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Lex Ruiters
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Arnoud W J van ‘t Hof
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
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Wu L, Yu J, Wang Q, Lu Y. Effects of nalbuphine on the cardioprotective effect of morphine in rats. Int J Cardiol 2020; 322:207-210. [PMID: 32828962 DOI: 10.1016/j.ijcard.2020.08.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/03/2020] [Accepted: 08/17/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND When combined with morphine, nalbuphine not only does not affect the analgesic effect but also prevents opioid-induced side effects. The authors investigated whether nalbuphine interferes with morphine-induced cardioprotection in rats. METHODS Anesthetized male Sprague-Dawley rats were randomly assigned to 1 of 4 treatment groups. Nalbuphine (NAL, 1 mg/kg) and morphine (MOR, 0.3 mg/kg) were administered 10 and 5 min prior to myocardial ischemia, respectively. Additionally, the NAL + MOR group received the combination of NAL and MOR prior to myocardial ischemia. An in vivo animal model was established by occluding the left anterior descending artery for 30 min and reperfusing it for 2 h. After 2 h of reperfusion, the infarcted area of heart was measured by Evans blue/triphenyl tetrazolium staining, and the levels of creatine kinase isoenzymes (CK-MB) in serum were detected by enzyme-linked immunosorbent assay. RESULTS Nalbuphine had no protective effect against the infarct area compared with the control treatment (NAL, 52.5 ± 5% versus CON, 52.6 ± 4%; *P < 0.01), and the infarct size-sparing effects of morphine were not affected by nalbuphine (NAL + MOR, 42.6 ± 7% versus MOR, 40.4 ± 3%; P > 0.05). The nalbuphine group did not show a change the levels of serum CK-MB compared with the control group, and nalbuphine did not affect the levels of serum CK-MB in the MOR group. CONCLUSIONS Nalbuphine does not interfere with the cardioprotective effect of morphine in vivo. Therefore, nalbuphine could be safely used or combined with morphine in patients with acute myocardial infarction.
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Affiliation(s)
- Lining Wu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230061, PR China; Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University, Hefei 230022, PR China
| | - Junma Yu
- Department of Anesthesiology, The Third Affiliated Hospital of Anhui Medical University, Hefei 230022, PR China; Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230061, PR China
| | - Qiuyue Wang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230061, PR China
| | - Yao Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230061, PR China.
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Deng Q, Zhang S, Li M, Zhang G, Feng W. Effects of two different glycoprotein platelet IIb/IIIa inhibitors and the clinical endpoints in patients with intracranial Pipeline flow diverter implant. J Interv Med 2020; 3:174-179. [PMID: 34805930 PMCID: PMC8562166 DOI: 10.1016/j.jimed.2020.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/11/2020] [Accepted: 08/03/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the antiplatelet effect and major adverse cerebrovascular events of Pipeline for intracranial aneurysms using glycoprotein IIb/IIIa antagonists (GPI) eptifibatide and tirofiban. Methods Retrospective analysis of relevant data of patients using GPIs combined with oral antiplatelet therapy in Nanfang Hospital of Southern Medical University from December 2017 to December 2019. The study was approved by the ethics Committee of Nanfang Hospital of Southern Medical University. According to the random use of GPIs drugs, they were assigned to the eptifibatide group and tirofiban group. Basic data, platelet inhibition rates at baseline, 24h and 72h after administration, short-term major adverse cerebrovascular events, and bleeding complications were compared between the two groups. Results A total of 47 patients were included in this study, including 24 patients in eptifibatide group and 23 patients in tirofiban group. There was no significant difference in average age (53.75 vs. 53.91 years) and body mass index (BMI) (24.39 vs. 22.73 kg/m2) between eptifibatide group and tirofiban group. There was no significant difference in coagulation factor function (R), fibrinogen function (K), fibrinolysis function (EPL), comprehensive coagulation index (Cl), arachidonic acid pathway inhibition rate (AA%) and adenosine diphosphate inhibition rate (ADP%). However, the baseline level of residual platelet function MA (ADP) in eptifibatide group was significantly higher than that in tirofiban group (50.79 vs. 35.29 mm, P = 0.0026). There was a statistical difference in the platelet aggregation function MA (65.38 vs. 62.54 mm, p = 0.0442), the rate of spontaneous hemorrhagic stroke (4.3% vs. 0%) and the rate of asymptomatic minor bleeding (26.08% vs. 4.1%) in the two groups (P < 0.05). Conclusion Both eptifibatide and tirofiban can effectively inhibit platelets, but the effect of etifeptide is better than that of tirofiban in preventing intracranial microhemorrhage and asymptomatic cerebral infarction.
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Affiliation(s)
| | | | | | | | - Wenfeng Feng
- Corresponding author. Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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Gue YX, Spinthakis N, Farag M, Kubica J, Siller-Matula JM, Srinivasan M, Gorog DA. Impact of Preadmission Morphine on Reinfarction in Patients With ST-Elevation Myocardial Infarction Treated With Percutaneous Coronary Intervention: A Meta-Analysis. Clin Pharmacol Ther 2020; 108:54-62. [PMID: 31990051 DOI: 10.1002/cpt.1798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/06/2020] [Indexed: 11/11/2022]
Abstract
Opiates are the traditional analgesics used in patients with ST-elevation myocardial infarction (STEMI). Pharmacodynamic studies indicate that opiates delay the absorption of orally administered P2Y12 inhibitors and the onset of platelet inhibition. Whether these negative effects on platelet inhibition have an impact on clinical outcomes is unclear. A systematic review and meta-analysis was performed searching PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials to identify studies comparing morphine and no-morphine treatment in STEMI patients undergoing primary percutaneous coronary intervention. The primary end point was the occurrence of in-hospital myocardial infarction, and secondary end points were in-hospital stroke and death. Four observational studies were identified, including 3,220 patients with STEMI. Morphine-treated patients had a higher unadjusted rate of reinfarction compared with patients not receiving morphine (1.5% vs. 0.67%, odds ratio (OR) 2.41; 95% confidence interval (CI), 1.11-5.21; P = 0.03). Unadjusted mortality rate was lower in morphine-treated patients (1.7% vs. 4.2%, OR 0.43, 95% CI, 0.23-0.81; P = 0.009). Exclusion of the study with baseline differences between groups showed more frequent reinfarction in the morphine group, but this was no longer statistically significant (1.3% vs. 0.5%, OR 2.02; 95% CI, 0.39-10.43; P = 0.40). There was no difference in stroke according to morphine treatment. Patients pretreated with morphine appear to have a higher rate of reinfarction than patients not receiving morphine. This may be attributable to opiate-related delay in P2Y12 inhibitor absorption and resultant delay in onset of platelet inhibition. These concerning findings indicate the need for prospective, randomized trials to assess the impact of opiates on clinical outcomes in STEMI.
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Affiliation(s)
- Ying X Gue
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK.,Cardiology Department, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Nikolaos Spinthakis
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK.,Cardiology Department, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Mohamed Farag
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK.,Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jolanta M Siller-Matula
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Manivannan Srinivasan
- Cardiology Department, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Diana A Gorog
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK.,Cardiology Department, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.,National Heart & Lung Institute, Imperial College, London, UK
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Drug-Drug Interactions in Acute Coronary Syndrome Patients: Systematic Review. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0070] [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] Open
Abstract
Abstract
Drug-drug interaction (DDI) is defined as a clinically significant change in the exposure and/or response to a drug caused by co-administration of another drug which may result in a precipitation of an adverse event or alteration of its therapeutic effects. The aim of this systematic review was to provide an overview of DDIs that were actually observed or evaluated in acute coronary syndrome (ACS) patients with particular focus on DDIs with clinical relevance. Electronic searches of the literature were conducted in the following databases: MEDLINE, EBSCO, Scopus, Google Scholar and SCIndeks. A total of 117 articles were included in the review. This review showed that ACS patients can be exposed to a variety of DDIs with diverse outcomes which include decreased efficacy of antiplatelet drugs, thrombolytics or anticoagulants, increased risk of bleeding, rhabdomyolysis, hepatotoxicity, adverse effects on cardiovascular system (e.g. QT interval prolongation, arrhythmias, excessive bradycardia, severe hypotension), serotonin syndrome and drug-induced fever. Majority of the DDIs involved antiplatelet drugs (e.g. aspirin, clopidogrel and ticagrelor). Evidence of some of the reported DDIs is inconclusive as some of the studies have shown conflicting results. There is a need for additional post-marketing and population-based studies to evaluate the true effects of disease states and other factors on the clinical outcomes of DDIs. Clinicians should be attentive to the potential for DDIs and their associated harm in order to minimize or, if possible, avoid medication-related adverse events in ACS 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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Alexopoulos D, Varlamos C, Mpahara A, Lianos I. P2Y12 inhibitors for the treatment of acute coronary syndrome patients undergoing percutaneous coronary intervention: current understanding and outcomes. Expert Rev Cardiovasc Ther 2019; 17:717-727. [PMID: 31583920 DOI: 10.1080/14779072.2019.1675513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Inhibition of P2Y12 platelet receptors consists a crucial target of pharmacologic treatment in acute coronary syndrome patients. Several controversial issues however still remain and these are analyzed.Areas covered: The significance of early and strong platelet inhibition in the early phase of STEMI and the role of pretreatment are discussed. Concerns regarding morphine administration are raised. The role of crushing integral tablets to expedite the onset of action of oral P2Y12 inhibitors is emphasized. New data on the intravenous cangrelor are reported. Antiplatelet therapies as adjunct to thrombolysis, as well as the role of de-escalation antiplatelet therapy are analyzed.Expert opinion: Pharmacodynamic studies convincingly demonstrate a gap in the onset of antiplatelet action in STEMI cases, even when prasugrel or ticagrelor loading dose is used. The clinical benefit, however, of the early platelet inhibition and pretreatment is not entirely clear. Morphine delays the onset of action of oral agents, while this is expedited by crushing the integral tablets. Cangrelor devoids of these deficiencies by achieving fast and strong platelet inhibition in all clinical scenarios. Concomitant administration of novel antiplatelet agents with thrombolysis and de-escalation of antiplatelet treatment necessitate further study to reach definite conclusion.
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Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Aikaterini Mpahara
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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17
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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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