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Wang XM, Li XX, Jiang B, Wang TQ, Guo Z. Morphine timing-dependent modulation of TRPV1 phosphorylation correlates with differential morphine effects on myocardial ischemia/reperfusion injury. Eur J Pharmacol 2024; 975:176648. [PMID: 38759706 DOI: 10.1016/j.ejphar.2024.176648] [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: 02/17/2024] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 05/19/2024]
Abstract
Opioids are used for pain relief in patients suffering from acute myocardial ischemia or infarction. Clinical and laboratory studies demonstrate that morphine treated patients or the experimental animal model suffering acute myocardial ischemia and reperfusion, may worsen myocardial viability. As transient receptor potential vanilloid 1 (TRPV1) plays important roles in pain sensation and cardio-protection, we query whether opioids may exacerbate myocardial viability via interaction with TRPV1 activity in the pain relief. We found the co-expressions of TRPV1 and opioid μ, δ and κ receptors in adult rat cardiomyocytes. Intravenous injection of morphine (0.3 mg/kg) at 20 min after induction of myocardial ischemia, in the rat model of acute myocardial ischemia and reperfusion, induced significant reduction of phosphorylated TRPV1 (p-TRPV1) in the ventricular myocardium and increase in serum cardiac troponin I (cTnI), compared with the ischemia/reperfusion controls (all P < 0.05). The effects of morphine were completely reversed by selective opioid μ, δ and κ receptor antagonists. While significant upregulation of p-TRPV1 (P < 0.05) and improvement of ±dP/dt max (all P < 0.05) were detected in the animals giving the same dose of morphine before induction of myocardial ischemia. The changes in p-TRPV1 correlate with the alterations of cTnI (r = -0.5840, P = 0.0283) and ±dP/dt max (r = 0.8084, P = 0.0005 and r = -0.8133, P = 0.0004, respectively). The findings of this study may indicate that potentiation and attenuation of TRPV1 sensitivity correlate with the improvement of the cardiac performance and the aggravation of myocardial viability, respectively, by giving morphine before and during myocardial ischemia and reperfusion.
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Affiliation(s)
- Xin-Meng Wang
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China
| | - Xiao-Xi Li
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China; Department of Anaesthesia, Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, Shanxi, China
| | - Bo Jiang
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China
| | - Tian-Qi Wang
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China
| | - Zheng Guo
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China; Department of Anaesthesia, Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, Shanxi, China; Key Laboratory of Cellular Physiology (Shanxi Medical University), National Education Commission, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China.
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2
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Chodnekar SY, Jain N, Lansiaux E, Panag DS, Gibietis V. Beyond Traditional Pain Relief: A Review of Alternative Analgesics in Myocardial Infarction Patient Management. J Pain Palliat Care Pharmacother 2024; 38:157-169. [PMID: 38329476 DOI: 10.1080/15360288.2024.2304008] [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: 10/11/2023] [Accepted: 01/07/2024] [Indexed: 02/09/2024]
Abstract
While morphine is the recommended first-line treatment for pain management in patients with acute coronary syndrome, recent studies have raised concerns about its association with adverse outcomes. Morphine has been found to cause delayed antiplatelet effects, decreased ticagrelor absorption, increased platelet reactivity, and compromised efficacy of dual antiplatelet therapy (DAPT). Alternative analgesics, such as lidocaine, fentanyl, and acetaminophen, have begun to emerge as viable alternatives, each with unique mechanisms and potential benefits. Lidocaine is demonstrated to have superior effects in reducing microvascular obstruction and fewer adverse events compared to fentanyl, despite being less effective in pain reduction. Fentanyl, which shows rapid onset and powerful analgesic properties, may interfere with ticagrelor absorption, potentially affecting platelet inhibition. Acetaminophen, a centrally acting analgesic, emerges as a safer alternative with comparable pain relief efficacy and minimal side effects. The results of multiple clinical trials emphasize the significance of customizing pain management approaches to match individual patient profiles and achieving the optimal balance between pain relief and potential adverse outcomes.
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Affiliation(s)
| | - Nityanand Jain
- Faculty of Medicine, Riga Stradinš University, Riga, Latvia
| | - Edouard Lansiaux
- Faculty of Medicine, Lille University School of Medicine, Lille, France
| | | | - Valdis Gibietis
- Department of Internal Diseases, Riga Stradinš University, Riga, Latvia
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3
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Ouyang C, Meng C, Li F, Nie S, Gong L, Cao Y, Yuan H, Feng Z. Assessing the Impact of Morphine on Adverse Outcomes in ACS Patients Treated with P2Y12 Inhibitors: Insights from Multiple Real-World Evidence. Drug Des Devel Ther 2024; 18:1811-1819. [PMID: 38828024 PMCID: PMC11143443 DOI: 10.2147/dddt.s458299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/01/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Mechanistic studies showed that morphine may impair the antiplatelet effect of P2Y12 inhibitors. However, Several clinical studies with cardiovascular events as an outcome are contradictory, and the broader impact of this drug interaction on additional organ systems remains uncertain. With multisource data, this study sought to determine the effects of morphine interaction with P2Y12 inhibitors on major adverse outcomes comprehensively, and identify the warning indicators. Patients and Methods Interaction signals were sought in 187,919 safety reports from the FDA Adverse Event Reporting System (FAERS) database, utilizing reporting odds ratios (repOR). In a cohort of 5240 acute coronary syndrome patients, the analyses were validated, and the biological effects of warning indicators were further studied with Mendelian randomization and mediation analysis. Results Potential risk of renal system adverse events in patients cotreated with morphine is significantly higher in FAERS (repOR 4.83, 95% CI 4.42-5.28, false discovery rate adjusted-P =3.55*10-209). The analysis of in-house patient cohorts validated these results with an increased risk of acute kidney injury (adjusted OR: 1.65; 95% CI: 1.20 to 2.26), and we also found a risk of myocardial infarction in patients treated with morphine (adjusted OR: 1.55; 95% CI: 1.14 to 2.11). The Morphine group exhibited diminished Plateletcrit (PCT) levels post-surgery and lower PCT levels were associated with an increased risk of AKI. Conclusion The administration of morphine in patients treated with P2Y12 receptor inhibitors should be carefully evaluated. PCT may serve as a potential warning indicator for morphine-related renal injury.
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Affiliation(s)
- Chenxi Ouyang
- School of Pharmacology, University of South China, Hengyang, Hunan, People’s Republic of China
- The Affiliated Nanhua Hospital, Department of Pharmacy, Hengyang Medical School University of South China, Hengyang, Hunan, People’s Republic of China
| | - Changjiang Meng
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
| | - Fei Li
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
| | - Shanshan Nie
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
| | - Liying Gong
- Department of Critical Care Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
| | - Yu Cao
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
| | - Hong Yuan
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, People’s Republic of China
| | - Zeying Feng
- Clinical Trial Institution Office, Liuzhou Hospital of Guangzhou Women and Children’s Medical Center, Liuzhou, Guangxi, People’s Republic of China
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4
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Garin D, Degrauwe S, Carbone F, Musayeb Y, Lauriers N, Valgimigli M, Iglesias JF. Differential impact of fentanyl and morphine doses on ticagrelor-induced platelet inhibition in ST-segment elevation myocardial infarction: a subgroup analysis from the PERSEUS randomized trial. Front Cardiovasc Med 2024; 11:1324641. [PMID: 38628315 PMCID: PMC11018886 DOI: 10.3389/fcvm.2024.1324641] [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] [Received: 10/19/2023] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Among patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), intravenous fentanyl does not enhance ticagrelor-induced platelet inhibition within 2 h compared to morphine. The impact of the total dose of fentanyl and morphine received on ticagrelor pharmacodynamic and pharmacokinetic responses in patients with STEMI remains however undetermined. Materials and methods We performed a post-hoc subanalysis of the prospective, open-label, single-center, randomized PERSEUS trial (NCT02531165) that compared treatment with intravenous fentanyl vs. morphine among symptomatic patients with STEMI treated with primary PCI after ticagrelor pretreatment. Patients from the same population as PERSEUS were further stratified according to the total dose of intravenous opioids received. The primary outcome was platelet reactivity using P2Y12 reaction units (PRU) at 2 h following administration of a loading dose (LD) of ticagrelor. Secondary outcomes were platelet reactivity and peak plasma levels of ticagrelor and AR-C124910XX, its active metabolite, at up to 12 h after ticagrelor LD administration. Generalized linear models for repeated measures were built to determine the relationship between raw and weight-weighted doses of fentanyl and morphine. Results 38 patients with STEMI were included between December 18, 2015, and June 22, 2017. Baseline clinical and procedural characteristics were similar between low- and high-dose opioid subgroups. At 2 h, there was a significant correlation between PRU and both raw [regression coefficient (B), 0.51; 95% confidence interval (CI), 0.02-0.99; p = 0.043] and weight-weighted (B, 0.54; 95% CI, 0.49-0.59; p < 0.001) doses of fentanyl, but not morphine. Median PRU at 2 h was significantly lower in patients receiving low, as compared to high, doses of fentanyl [147; interquartile range (IQR), 63-202; vs. 255; IQR, 183-274; p = 0.028], whereas no significant difference was found in those receiving morphine (217; IQR, 165-266; vs. 237; IQR, 165-269; p = 0.09). At 2 h, weight-weighted doses of fentanyl and morphine were significantly correlated to plasma levels of ticagrelor and AR-C124910XX. Conclusion In symptomatic patients with STEMI who underwent primary PCI after ticagrelor pretreatment and who received intravenous opioids, we found a dose-dependent relationship between the administration of intravenous fentanyl, but not morphine, and ticagrelor-induced platelet inhibition.
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Affiliation(s)
- Dorian Garin
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Sophie Degrauwe
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Federico Carbone
- Department of Internal Medicine, First Clinic of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa, Italian Cardiovascular Network, Genoa, Italy
| | - Yazan Musayeb
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Nathalie Lauriers
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Marco Valgimigli
- Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Juan F. Iglesias
- Department of Cardiology, Geneva University Hospitals, Geneva, Switzerland
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Ma X, Guo Z, Li MR, Chen L, Zhao X, Wang TQ, Sun T. Epidural administration of large dose of opioid μ receptor agonist may impair cardiac functions and myocardial viability via desensitizing transient receptor potential vanilloid 1. Toxicol Appl Pharmacol 2024; 483:116802. [PMID: 38184280 DOI: 10.1016/j.taap.2023.116802] [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: 08/31/2023] [Revised: 12/06/2023] [Accepted: 12/30/2023] [Indexed: 01/08/2024]
Abstract
The incidence of postoperative myocardial injury remains high as the underlying pathogenesis is still unknown. The dorsal root ganglion (DRG) neurons express transient receptor potential vanilloid 1 (TRPV1) and its downstream effector, calcitonin gene-related peptide (CGRP) participating in transmitting pain signals and cardiac protection. Opioids remain a mainstay therapeutic option for moderate-to-severe pain relief clinically, as a critical component of multimodal postoperative analgesia via intravenous and epidural delivery. Evidence indicates the interaction of opioids and TRPV1 activities in DRG neurons. Here, we verify the potential impairment of myocardial viability by epidural usage of opioids in postoperative analgesia. We found that large dose of epidural morphine (50 μg) significantly worsened the cardiac performance (+dP/dtmax reduction by 11% and -dP/dtmax elevation by 24%, all P < 0.001), the myocardial infarct size (morphine vs Control, 0.54 ± 0.09 IS/AAR vs. 0.23 ± 0.06 IS/AAR, P < 0.001) and reduced CGRP in the myocardium (morphine vs. Control, 9.34 ± 2.24 pg/mg vs. 21.23 ± 4.32 pg/mg, P < 0.001), while induced definite suppression of nociception in the postoperative animals. It was demonstrated that activation of μ-opioid receptor (μ-OPR) induced desensitization of TRPV1 by attenuating phosphorylation of the channel in the dorsal root ganglion neurons, via inhibiting the accumulation of cAMP. CGRP may attenuated the buildup of ROS and the reduction of mitochondrial membrane potential in cardiomyocytes induced by hypoxia/reoxygenation. The findings of this study indicate that epidurally giving large dose of μ-OPR agonist may aggravate myocardial injury by inhibiting the activity of TRPV1/CGRP pathway.
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Affiliation(s)
- Xiang Ma
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China
| | - Zheng Guo
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China; Department of Anaesthesia, Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan 030001, Shanxi, China; Key Laboratory of Cellular Physiology (Shanxi Medical University), National Education Commission, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China.
| | - Mu-Rong Li
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China
| | - Lu Chen
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China
| | - Xing Zhao
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China
| | - Tian-Qi Wang
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China
| | - Tao Sun
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan 030001, Shanxi, China
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6
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Droppa M, Geisler T. Optimal Antithrombotic Strategies in Cardiogenic Shock. J Clin Med 2024; 13:277. [PMID: 38202284 PMCID: PMC10779586 DOI: 10.3390/jcm13010277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/22/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
Cardiogenic shock (CS) represents a critical condition with a high mortality rate. The most common cause of CS is coronary artery disease, and patients typically present with myocardial infarction, necessitating immediate treatment through percutaneous coronary intervention (PCI) and often requiring mechanical circulatory support. CS is associated with a prothrombotic situation, while on the other hand, there is often a significant risk of bleeding. This dual challenge complicates the selection of an optimal antithrombotic strategy. The choice of antithrombotic agents must be personalized, taking into consideration all relevant conditions. Repeated risk assessment, therapeutic monitoring, and adjusting antithrombotic therapy are mandatory in these patients. This review article aims to provide an overview of the current evidence and practical guidance on antithrombotic strategies in the context of CS.
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Affiliation(s)
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital of Tuebingen, 72076 Tuebingen, Germany
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7
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Sirbu C. The Role of Endogenous Opioids in Cardioprotection. ADVANCES IN NEUROBIOLOGY 2024; 35:381-395. [PMID: 38874733 DOI: 10.1007/978-3-031-45493-6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
The opioid system involves opioid receptors (OPRs) and endogenous opioid peptides.This chapter will focus on the distribution of OPRs in the cardiovascular system, the expression pattern in the heart, the activation by opioid peptides, and the effects of OPRs activation with potential relevance in cardiovascular performance. In the heart, OPRs are co-expressed with beta adrenergic receptors (β-ARs) in the G-protein-coupled receptor (GPCR) superfamily, functionally cross-talk with β-Ars and modify catecholamine-induced effects. They are involved in cardiac contractility, energy metabolism, myocyte survival or death, vascular resistance. The effects of the opioid system in the regulation of systemic circulation at both the central and peripheral level are presented. The pathways are discussed under physiological (i.e., aging) and pathological conditions (atherosclerosis, heart failure, essential hypertension, ischemic stress). Stimulation of OPRs not only inhibits cardiac excitation-contraction coupling, but also protects the heart against hypoxic and ischemic injury. An enhanced sensitivity to opioids of endocrine organs and neuronal systems is operative in hypertensive patients. The opioid system can be pharmacologically engaged to selectively mimic these responses via cardiac and nervous signaling. The clinical opportunities for the use of cardioprotective effects of opioids require future investigations to provide more specific details of the impact on cardiac performance and electrophysiological properties.
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Affiliation(s)
- Cristina Sirbu
- Department of Cardiac Surgery and Transplantation, University Hospital Nancy-Brabois, Nancy, France
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8
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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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9
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Korsgaard S, Munch T, Horváth-Puhó E, Adelborg K, Christiansen CF, Pedersen L, Schmidt M, Sørensen HT. Preadmission Opioid Use and 1-Year Mortality Following Incident Myocardial Infarction: A Danish Population-Based Cohort Study (1997-2016). J Am Heart Assoc 2023; 12:e026251. [PMID: 36892067 PMCID: PMC10111518 DOI: 10.1161/jaha.122.026251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Background Opioid use has been linked to an increased risk of myocardial infarction and cardiovascular mortality, but the prognostic impact of opioid use before an incident myocardial infarction is largely unknown. Methods and Results We conducted a nationwide population-based cohort study including all patients hospitalized for an incident myocardial infarction in Denmark (1997-2016). Based on their last redeemed opioid prescription before admission, patients were categorized as current users (0-30 days), recent users (31-365 days), former users (>365 days), and nonusers. One-year all-cause mortality was calculated using the Kaplan-Meier method. Hazard ratios (HRs) were computed using Cox proportional hazards regression analyses, adjusting for age, sex, comorbidity, any preceding surgery within 6 months before the myocardial infarction admission, and medication use before the myocardial infarction admission. We identified 162 861 patients with an incident myocardial infarction. Of these, 8% were current opioid users, 10% were recent opioid users, 24% were former opioid users, and 58% were nonusers of opioids. One-year mortality was highest among current users (42.5% [95% CI, 41.7%-43.3%]) and lowest among nonusers (20.5% [95% CI, 20.2%-20.7%]). Compared with nonusers, current users had an elevated 1-year all-cause mortality risk (adjusted HR, 1.26 [95% CI, 1.22-1.30]). Following adjustment, neither recent users nor former users of opioids were at elevated risk. Conclusions Preadmission opioid use was associated with an increased 1-year all-cause mortality risk following an incident myocardial infarction. Opioid users thus represent a high-risk subgroup of patients with myocardial infarction.
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Affiliation(s)
- Søren Korsgaard
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Troels Munch
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Kasper Adelborg
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit Aarhus University Hospital Aarhus Denmark
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Lars Pedersen
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
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10
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Fernando H, Nehme Z, Dinh D, Andrew E, Brennan A, Shi W, Bloom J, Duffy SJ, Shaw J, Peter K, Nadurata V, Chan W, Layland J, Freeman M, Van Gaal W, Bernard S, Lefkovits J, Liew D, Stephenson M, Smith K, Stub D. Impact of prehospital opioid dose on angiographic and clinical outcomes in acute coronary syndromes. J Accid Emerg Med 2023; 40:101-107. [PMID: 35473753 DOI: 10.1136/emermed-2021-211519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/08/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND An adverse interaction whereby opioids impair and delay the gastrointestinal absorption of oral P2Y12 inhibitors has been established, however the clinical significance of this in acute coronary syndrome (ACS) is uncertain. We sought to characterise the relationship between prehospital opioid dose and clinical outcomes in patients with ACS. METHODS Patients given opioid treatment by emergency medical services (EMS) with ACS who underwent percutaneous coronary intervention (PCI) between 1 January 2014 and 31 December 2018 were included in this retrospective cohort analysis using data linkage between the Ambulance Victoria, Victorian Cardiac Outcomes Registry and Melbourne Interventional Group databases. Patients with cardiogenic shock, out-of-hospital cardiac arrest and fibrinolysis were excluded. The primary end point was the risk-adjusted odds of 30-day major adverse cardiac events (MACE) between patients who received opioids and those that did not. RESULTS 10 531 patients were included in the primary analysis. There was no significant difference in 30-day MACE between patients receiving opioids and those who did not after adjusting for key patient and clinical factors. Among patients with ST-elevation myocardial infarction (STEMI), there were significantly more patients with thrombolysis in myocardial infarction (TIMI) 0 or 1 flow pre-PCI in a subset of patients with high opioid dose versus no opioids (56% vs 25%, p<0.001). This remained significant after adjusting for known confounders with a higher predicted probability of TIMI 0/1 flow in the high versus no opioid groups (33% vs 11%, p<0.001). CONCLUSIONS Opioid use was not associated with 30-day MACE. There were higher rates of TIMI 0/1 flow pre-PCI in patients with STEMI prescribed opioids. Future prospective research is required to verify these findings and investigate alternative analgesia for ischaemic chest pain.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Bendigo Health, Bendigo, Victoria, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - William Shi
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bloom
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen James Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Voltaire Nadurata
- Department of Cardiology, Bendigo Health, Bendigo, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Jamie Layland
- Department of Cardiology, Peninsula Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Danny Liew
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia .,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia
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11
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Fernando H, Nehme Z, Milne C, O'Brien J, Bernard S, Stephenson M, Myles PS, Lefkovits J, Peter K, Brennan A, Dinh D, Andrew E, Taylor AJ, Smith K, Stub D. LidocAine Versus Opioids In MyocarDial infarction: the AVOID-2 randomized controlled trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:2-11. [PMID: 36494194 DOI: 10.1093/ehjacc/zuac154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/17/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
AIMS Opioid analgesia has been shown to interfere with the bioavailability of oral P2Y12 inhibitors prompting the search for safe and effective non-opioid analgesics to treat ischaemic chest pain. METHODS AND RESULTS The lidocAine Versus Opioids In MyocarDial infarction trial was a prospective, Phase II, prehospital, open-label, non-inferiority, randomized controlled trial enrolling patients with suspected STEACS with moderate to severe pain [numerical rating scale (NRS) at least 5/10]. Intravenous lidocaine (maximum dose 300 mg) or intravenous fentanyl (up to 50 µg every 5 min) were administered as prehospital analgesia. The co-primary end points were prehospital pain reduction and adverse events requiring intervention. Secondary end points included peak cardiac troponin I, cardiac MRI (cMRI) assessed myocardial infarct size and clinical outcomes to 30 days. A total of 308 patients were enrolled. The median reduction in pain score (NRS) was 4 vs. 3 in the fentanyl and lidocaine arms, respectively, for the primary efficacy end point [estimated median difference -1 (95% confidence interval -1.58, -0.42, P = 0.5 for non-inferiority, P = 0.001 for inferiority of lidocaine)]. Adverse events requiring intervention occurred in 49% vs. 36% of the fentanyl and lidocaine arms which met non-inferiority and superiority favouring lidocaine (P = 0.016 for superiority). No significant differences in myocardial infarct size and clinical outcomes at 30 days were seen. CONCLUSION IV Lidocaine did not meet the criteria for non-inferiority with lower prehospital pain reduction than fentanyl but was safe and better tolerated as analgesia in ST-elevation myocardial infarction (STEMI). Future trials testing non-opioid analgesics in STEMI and whether opioid avoidance improves clinical outcomes are needed. TRIAL REGISTRATION CTRN12619001521112p.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, 3785 Manningham Road, Doncaster, VIC 3108, Australia
| | - Catherine Milne
- Centre for Research and Evaluation, Ambulance Victoria, 3785 Manningham Road, Doncaster, VIC 3108, Australia
| | - Jessica O'Brien
- Department of Cardiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Stephen Bernard
- Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Centre for Research and Evaluation, Ambulance Victoria, 3785 Manningham Road, Doncaster, VIC 3108, Australia
| | - Michael Stephenson
- Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Centre for Research and Evaluation, Ambulance Victoria, 3785 Manningham Road, Doncaster, VIC 3108, Australia
| | - Paul S Myles
- Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred and Monash University, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Jeffrey Lefkovits
- Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan St, Parkville VIC 3050, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Angela Brennan
- Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Diem Dinh
- Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance Victoria, 3785 Manningham Road, Doncaster, VIC 3108, Australia
| | - Andrew J Taylor
- Department of Cardiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Karen Smith
- Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Centre for Research and Evaluation, Ambulance Victoria, 3785 Manningham Road, Doncaster, VIC 3108, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,Monash University, School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Department of Cardiology, Western Health, Eleanor St, Footscray, VIC 3011, Australia
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12
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Gharbin J, Winful A, Hassan MA, Bajaj S, Batta Y, Alebna P, Rhodd S, Taha M, Fatima U, Mehrotra P. Differences in the Clinical Outcome of Ischemic and Nonischemic Cardiomyopathy in Heart Failure With Concomitant Opioid Use Disorder. Curr Probl Cardiol 2023; 48:101609. [PMID: 36690309 DOI: 10.1016/j.cpcardiol.2023.101609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
Heart Failure (HF) and Opioid Use Disorder (OUD) independently have significant impact on patients and the United States (US) health system. In the setting of the opioid epidemic, research on the effects of OUD on cardiovascular diseases is rapidly evolving. However, no study exists on differential outcomes of ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM) in patients with HF with OUD. We performed a retrospective, observational cohort study using National Inpatient Sample (NIS) 2018-2020 databases. Patients aged 18 years and above with diagnoses of HF with concomitant OUD were included. Patients were further classified into ICM and NICM. Primary outcome of interest was differences in all- cause in-hospital mortality. Secondary outcome was incidence of cardiogenic shock. We identified 99,810 hospitalizations that met inclusion criteria, ICM accounted for 27%. Mean age for ICM was higher compared to NICM (63 years vs 56 years, P < 0.01). Compared to NICM, patients with ICM had higher cardiovascular disease risk factors and comorbidities; type 2 diabetes mellitus (46.3 % vs 30.1%, P < 0.01), atrial fibrillation/flutter (33.5% vs 29.9%, P < 0.01), hyperlipidemia (52.5% vs 28.9%, P < 0.01), and Charlson comorbidity index ≥5 was 46.7% versus 29.7%, P < 0.01. After controlling for covariates and potential confounders, we observed higher odds of all-cause in-hospital mortality in patients with NICM (aOR = 1.36; 95% CI:1.03-1.78, P = 0.02). There was no statistical significant difference in incidence of cardiogenic shock between ICM and NICM (aOR = 0.86;95% CI 0.70-1.07, P = 0.18). In patients with HF with concomitant OUD, we found a 36% increase in odds of all-cause in-hospital mortality in patients with NICM compared to ICM despite being younger in age with less comorbidities. There was no difference in odds of in-hospital cardiogenic shock in this study population. This study contributes to the discussion of OUD and cardiovascular diseases which is rapidly developing and requires further prospective studies.
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Affiliation(s)
- John Gharbin
- Department of Medicine, Howard University Hospital, Washington DC, USA.
| | - Adwoa Winful
- Department of Hospital Medicine, Doctors Hospital of Augusta, Augusta, GA, USA
| | | | - Siddharth Bajaj
- Department of Medicine, Howard University Hospital, Washington DC, USA
| | | | - Pamela Alebna
- Department of Medicine, RWJ Barnabas Health, Jersey City, NJ, USA
| | - Suchellis Rhodd
- Division of Cardiovascular Disease, Howard University Hospital, Washington, DC, USA
| | - Mohammed Taha
- Division of Cardiovascular Disease, Howard University Hospital, Washington, DC, USA
| | - Urooj Fatima
- College of Medicine, Howard University, Washington, DC, USA; Division of Cardiovascular Disease, Howard University Hospital, Washington, DC, USA
| | - Prafulla Mehrotra
- College of Medicine, Howard University, Washington, DC, USA; Division of Cardiovascular Disease, Howard University Hospital, Washington, DC, USA
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13
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Rafie N, Matchett CL, Jentzer JC. 38-Year-Old Woman With Chest Pain. Mayo Clin Proc 2023; 98:187-192. [PMID: 36603947 DOI: 10.1016/j.mayocp.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Nikita Rafie
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Caroline L Matchett
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Jacob C Jentzer
- Advisor to residents and Consultant in Cardiovascular Medicine and Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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14
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Mason JM, O’Brien ME, Koehl JL, Ji CS, Hayes BD. Cardiovascular Pharmacology. Emerg Med Clin North Am 2022; 40:771-792. [DOI: 10.1016/j.emc.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Kubica J. Opioids and oral P2Y12 receptor inhibitors: A drug-drug interaction. Cardiol J 2022; 29:727-729. [PMID: 36196657 PMCID: PMC9550322 DOI: 10.5603/cj.2022.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 06/30/2022] [Indexed: 11/25/2022] Open
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16
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Abstract
INTRODUCTION Platelets play a key role in arterial thrombosis and antiplatelet therapy is pivotal in the treatment of cardiovascular disease. Current antiplatelet drugs target different pathways of platelet activation and show specific pharmacodynamic and pharmacokinetic characteristics, implicating clinically relevant drug-drug interactions. AREAS COVERED This article reviews the role of platelets in hemostasis and cardiovascular thrombosis, and discusses the key pharmacodynamics, drug-drug interactions and reversal strategies of clinically used antiplatelet drugs. EXPERT OPINION Antiplatelet therapies target distinct pathways of platelet activation: thromboxane A2 synthesis, adenosine diphosphate-mediated signaling, integrin αIIbβ3 (GPIIb/IIIa), thrombin-mediated platelet activation via the PAR1 receptor and phosphodiesterases. Key clinical drug-drug interactions of antiplatelet agents involve acetylsalicylic acid - ibuprofen, clopidogrel - omeprazole, and morphine - oral P2Y12 inhibitors, all of which lead to an attenuated antiplatelet effect. Platelet function and genetic testing and the use of scores (ARC-HBR, PRECISE-DAPT, ESC ischemic risk definition) may contribute to a more tailored antiplatelet therapy. High on-treatment platelet reactivity presents a key problem in the acute management of ST-elevation myocardial infarction (STEMI). A treatment strategy involving early initiation of an intravenous antiplatelet agent may be able to bridge the gap of insufficient platelet inhibition in high ischemic risk patients with STEMI.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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17
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Cantor WJ, Tan M, Berwanger O, Lavi S, White HD, Nicolau JC, Dehghani P, Tajer CD, Lopes RD, Moia DDF, Nicholls SJ, Parkhomenko A, Averkov O, Brass N, Lutchmedial S, Malaga G, Damiani LP, Piegas LS, Granger CB, Goodman SG. Morphine and clinical outcomes in patients with ST segment elevation myocardial infarction treated with fibrinolytic and antiplatelet therapy: Insights from the TREAT trial. Am Heart J 2022; 251:1-12. [PMID: 35533724 DOI: 10.1016/j.ahj.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/22/2022] [Accepted: 05/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Morphine is commonly used to relieve pain, anxiety and dyspnea in STEMI but it lowers blood pressure and delays the activity of oral antiplatelet agents. The impact of morphine on clinical outcomes remains unknown. This analysis was performed to determine if morphine use was associated with increased risk of adverse clinical events among STEMI patients treated with fibrinolytic therapy and clopidogrel or ticagrelor. METHODS In the Ticagrelor in Patients with ST Elevation Myocardial Infarction Treated with Pharmacological Thrombolysis (TREAT) study, 3799 STEMI patients treated with fibrinolysis were randomized to receive clopidogrel or ticagrelor. Morphine use was left to the discretion of the treating physicians. In this pre-specified analysis, we evaluated clinical outcomes based on the use and timing of morphine administration. Outcomes were stratified by randomized treatment group. Multivariable analysis was performed using Inverse Probability Treatment Weighting (IPTW) weighting. RESULTS Morphine was used in 53% of patients. After adjustment using IPTW weighting, morphine use was associated with higher hazard of reinfarction at 7 days (HR 4.9, P = .0006) and 30 days (HR 1.7, P = .04), and lower hazard of major bleeding (HR 0.37, P = .006). There was no significant difference in mortality at any time point. CONCLUSIONS Among patients with STEMI treated with fibrinolytic therapy, morphine use was associated with a higher risk of early reinfarction and a lower risk of major bleeding but no difference in mortality. CLINICAL TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02298088.
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Affiliation(s)
- Warren J Cantor
- Department of Medicine, Southlake Regional Health Centre, University of Toronto, 581 Davis Drive, Newmarket, Toronto, Ontario L3Y 2P6, Canada.
| | - Mary Tan
- Department of Medicine, Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Shahar Lavi
- Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Harvey D White
- Department of Medicine, Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Payam Dehghani
- Department of Medicine, Prairie Vascular Research Network and Saskatchewan Health Authority, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Carlos D Tajer
- Department of Medicine, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Renato D Lopes
- Department of Medicine, Duke Clinical Research Institute, Durham, NC, United States; Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Diogo D F Moia
- Clinical Operations, Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | - Stephen J Nicholls
- Department of Medicine, Monash Cardiovascular Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Alexander Parkhomenko
- Department of Medicine, Emergency Cardiology Department, Institute of Cardiology, Kiev, Ukraine
| | - Oleg Averkov
- Department of Medicine, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Neil Brass
- Department of Medicine, CK Hui Heart Centre, Edmonton, Alberta, Canada
| | - Sohrab Lutchmedial
- Department of Medicine, New Brunswick Heart Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Germán Malaga
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Lucas P Damiani
- Clinical Operations, Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | | | | | - Shaun G Goodman
- Department of Medicine, Canadian Heart Research Centre (CHRC) and Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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18
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Song IA, Choi HR, Oh TK. Long-term opioid use and mortality in patients with chronic non-cancer pain: Ten-year follow-up study in South Korea from 2010 through 2019. EClinicalMedicine 2022; 51:101558. [PMID: 35875817 PMCID: PMC9304910 DOI: 10.1016/j.eclinm.2022.101558] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We aimed to investigate the prevalence and factors associated with long-term opioid use among patients with chronic non-cancer pain (CNCP). METHODS We extracted data from the National Health Insurance Service (NHIS) database in South Korea. As a nationwide database, the NHIS database contains information regarding all disease diagnoses and prescriptions for any drug and/or procedures. A total of 2.5% of adult patients (≥20 years of age) who were diagnosed with musculoskeletal diseases and CNCP from 2010 to 2019 were selected using a stratified random sampling technique and included in the analysis. Patients who were prescribed opioids continuously for ≥90 days were classified as long-term opioid users. FINDINGS A total of 19,645,161 patients with CNCP were included in the final analysis. The prevalence of long-term opioid use was 0.47% (95% confidence interval [CI]: 0.46%, 0.48%; 8421/1,808,043) in 2010, which gradually increased to 2.63% (95% CI: 2.61%, 2.66%; 49,846/1,892,913) in 2019. Among the 2010 cohort (n = 1,804,019), in multivariable logistic regression: old age, underlying disability, increased Charlson comorbidity index, use of benzodiazepine or Z-drug, rheumatoid arthritis, osteoarthritis, and low back pain were associated with an increased prevalence of long-term opioid use among patients with CNCP. In a multivariable Cox regression, the 10-year all-cause mortality in long-term opioid users was found to be 1·21-fold (hazard ratio: 1.21, 95% CI: 1.13, 1.31; P<0·001) higher than that in opioid-naive patients with CNCP. INTERPRETATION Long-term opioid use increased in patients with CNCP in South Korea from 2010 to 2019. Certain factors were potential risk factors for long-term opioid use. Moreover, long-term opioid use was associated with increased 10-year all-cause mortality among patients with CNCP. FUNDING None.
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Affiliation(s)
- In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hey-ran Choi
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Corresponding author at: Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro, 173, Beon-gil, Bundang-gu, Seongnam, 13620, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
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19
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Abu Taha A, AbuRuz ME, Momani A. Morphine Use Did Not Eliminate the Effect of Pain on Complications After Acute Myocardial Infarction. Open Nurs J 2022. [DOI: 10.2174/18744346-v16-e2206202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Patients with Acute Myocardial Infarction (AMI) are usually present complaining of severe chest pain. This pain results from an imbalance between oxygen supply and demand, leading to severe complications. Different guidelines recommend using Morphine as a drug of choice for treating this pain.
Objective:
This study aimed to check the effect of chest pain and Morphine use on complications rate after AMI.
Methods:
This was a prospective observational study with a consecutive sample of 300 patients with AMI. Data were collected by direct patients interview and medical records review in the emergency departments & Intensive Care Units (ICU). Any complication developed within the hospital stay and after AMI was recorded. All correlated variables were analyzed using the binary logistic regression model.
Results:
The sample included 176 (58.7%) men and 124 (41.3%) women with a mean age of 56.92±12.13 years. A total of 83 patients (27.7%) developed one or more in-hospital complications. Acute recurrent ischemia was the most frequent complication; 70 (23.3%). Severe chest pain (≥ 7), duration of chest pain (more than 5 minutes), history of previous MI, and history of hypertension increased the occurrence of complications by 13%, 7%, 63%, and 25%, respectively. However, the use of Morphine did not have any protective effect against the development of these complications.
Conclusion:
The severity and duration of chest pain increased the occurrence of complications. Morphine administration did not have any protective effect against the development of these complications. Thus, it is recommended to update different policies and guidelines to use other types of chest pain relief methods, e.g., treating the underlying cause of chest pain and addressing the imbalance between oxygen supply and demand.
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20
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Liew SM, Chowdhury EK, Ernst ME, Gilmartin‐Thomas J, Reid CM, Tonkin A, Neumann J, McNeil JJ, Kaye DM. Prescribed opioid use is associated with adverse cardiovascular outcomes in community-dwelling older persons. ESC Heart Fail 2022; 9:3973-3984. [PMID: 35985663 PMCID: PMC9773735 DOI: 10.1002/ehf2.14101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/13/2022] [Accepted: 07/19/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS Prescribed opioids are commonly used in the older community-dwelling population for the treatment of chronic pain. Although the harmful effects of opioid abuse and overdose are well understood, little is known about the long-term cardiovascular (CV) effects of prescribed opioids. The aim of this study was to investigate the CV effects associated with prescribed opioid use. METHODS AND RESULTS A post hoc analysis of participants in the Aspirin in Reducing Events in the Elderly (ASPREE) trial was conducted. Participants in the ASPREE trial included community-dwelling older adults without a prior history of CV disease (CVD). Prescribed opioid use was defined as opioid use at baseline and/or at the first annual visit (AV1). Cox proportional hazards regression was used to calculate hazard ratios and 95% confidence intervals (95% CI) for associations between opioid use and CVD events following AV1. Of the 17 701 participants included (mean age 75.2 years, 58.2% female), 813 took opioids either at baseline or at AV1. Over a median follow-up period of 3.58 years (IQR 2.50-4.62), CVD events, most notably heart failure hospitalization, occurred in 7% (n = 57) amongst opioid users and 4% (n = 680) amongst non-opioid users. After adjustment for multiple covariates, opiate use was associated with a 1.67-fold (CI 1.26-2.23, P < 0.001) increase in the hazard ratio for CVD events. CONCLUSIONS These findings identify opioid use as a non-traditional risk factor for CVD events in community-dwelling older adults.
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Affiliation(s)
- Stephanie M. Liew
- Cardiology DepartmentAlfred HospitalMelbourneVICAustralia,Department of CardiologyUniversity Hospital GeelongGeelongVICAustralia
| | - Enayet K. Chowdhury
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Michael E. Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy and Department of Family Medicine, Carver College of MedicineThe University of IowaIowa CityIAUSA
| | - Julia Gilmartin‐Thomas
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Christopher M. Reid
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia,School of Population HealthCurtin UniversityPerthWAAustralia
| | - Andrew Tonkin
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia,Department of CardiologyAustin HealthMelbourneVICAustralia
| | - Johannes Neumann
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia,Department of CardiologyUniversity Medical Centre HamburgHamburgGermany
| | - John J. McNeil
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - David M. Kaye
- Cardiology DepartmentAlfred HospitalMelbourneVICAustralia,Department of CardiologyUniversity Medical Centre HamburgHamburgGermany,Baker Heart and Diabetes InstituteMelbourneAustralia
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Dehe L, Mousa SA, Shaqura M, Shakibaei M, Schäfer M, Treskatsch S. Naltrexone-Induced Cardiac Function Improvement is Associated With an Attenuated Inflammatory Response and Lipid Perioxidation in Volume Overloaded Rats. Front Pharmacol 2022; 13:873169. [PMID: 35847039 PMCID: PMC9280420 DOI: 10.3389/fphar.2022.873169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
In previous studies, upregulation of myocardial opioid receptors as well as the precursors of their endogenous ligands were detected in the failing heart due to chronic volume overload. Moreover, opioid receptor blockade by naltrexone improved left ventricular function. In parallel, inflammatory processes through cytokines have been confirmed to play an important role in the pathogenesis of different forms of heart failure. Thus, the present study examined the systemic and myocardial inflammatory response to chronic volume overload and its modulation by chronic naltrexone therapy. Chronic volume overload was induced in male Wistar rats by applying an infrarenal aortocaval fistula (ACF) for 28 days during which the selective opioid receptor antagonist naltrexone (n = 6) or vehicle (n = 6) were administered via a subcutaneously implanted Alzet minipump. The ultrastructural, morphometric and hemodynamic characterization of ACF animals were performed using an intraventricular conductance catheter in vivo and electron microscopy in vitro. Co-localization of mu-, delta- and kappa-opioid receptor subtypes (MOR, DOR, and KOR respectively) with the voltage gated L-type Ca2+ channel (Cav1.2), the ryanodine receptor (RyR), and mitochondria in cardiomyocytes as well as IL-6, IL-12, TNF-alpha, and Malondialdehyde (MDA) were determined using double immunofluorescence confocal microscopy, RT-PCR and ELISA, respectively. In rat left ventricular myocardium, three opioid receptor subtypes MOR, DOR, and KOR colocalized with Cav1.2, RyR and mitochondria suggesting a modulatory role of the excitation-contraction coupling. In rats with ACF-induced volume overload, signs of heart failure and myocardial ultrastructural damage, chronic naltrexone therapy improved cardiac function and reversed the systemic and myocardial inflammatory cytokine expression as well as lipid peroxidation. In conclusion, antagonism of the cardiodepressive effects of the myocardial opioid system does not only improve left ventricular function but also blunts the inflammatory response and lipid peroxidation.
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Affiliation(s)
- Lukas Dehe
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Shaaban A. Mousa
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany
- *Correspondence: Shaaban A. Mousa,
| | - Mohammed Shaqura
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Mehdi Shakibaei
- Institute of Anatomy, Ludwig-Maximilians-Universität München, München, Germany
| | - Michael Schäfer
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany
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Association of obstructive sleep apnea and opioids use on adverse health outcomes: A population study of health administrative data. PLoS One 2022; 17:e0269112. [PMID: 35763495 PMCID: PMC9239451 DOI: 10.1371/journal.pone.0269112] [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: 01/20/2022] [Accepted: 05/13/2022] [Indexed: 11/19/2022] Open
Abstract
Rationale
Despite the high prevalence of obstructive sleep apnea (OSA) and concurrent use of opioid therapy, no large-scale population studies have investigated whether opioid use and pre-existing OSA may interact synergistically to increase the risk of adverse health consequences. To address this knowledge gap, we conducted a retrospective cohort study using provincial health administrative data to evaluate whether the combined presence of opioid use and OSA increases the risk of adverse health consequences, such as mortality, hospitalizations, and emergency department (ED) visits; and if it does, whether this co-occurrence has synergistic clinical relevance.
Methods
We included all adults who underwent a diagnostic sleep study in Ontario, Canada, between 2013 and 2016. Individuals were considered exposed to opioids if they filled a prescription that overlapped with the date of their sleep study (Opioid+). Individuals with at least a 50% probability of having a diagnosis of moderate to severe OSA (OSA+) were identified using a previously externally validated case-ascertainment model. The primary outcome was all-cause mortality; secondary outcomes were all-cause or ischemic heart disease hospitalizations, all-cause ED visits, and motor vehicle collisions (MVC) requiring hospital or ED visit. We used multivariable Cox regression models to compare hazards between four mutually exclusive groups: (1) Opioid+ OSA+; (2) Opioid+ OSA-; (3) Opioid- OSA+, and (4) OSA- Opioid- (reference for comparison). Relative excess risks due to interaction (RERI) were calculated to test for additive interaction.
Results
Of 300,663 adults who underwent a sleep study, 15,713 (5.2%) were considered as Opioid+ and 128,351 (42.7%) as OSA+. Over a median of two years, 6,223 (2.1%) died from any cause. Regardless of OSA status, opioid use at the date of the sleep study was associated with an increased hazard for all-cause mortality with the greatest hazard associated with Opioid+ OSA- (adjusted hazard ratio [aHR]: 1.75, 95% CI 1.57–1.94), but not Opioid+ OSA+ (aHR: 1.14, 95% CI 1.02–1.27) as hypothesized. Regardless of OSA status, opioid use at the date of the sleep study was associated with an increased hazard for all secondary outcomes. Opioid+ OSA+ was associated with the greatest hazards of all-cause hospitalizations (aHR 1.55, 95% CI 1.49–1.61) and MVC (aHR of 1.39; 95% CI 1.09–1.77); however, no statistically significant synergistic effects were observed.
Conclusions
Adults referred for sleep disorder assessment who used opioids had a significantly increased hazard of adverse health outcomes than those who did not, regardless of whether they had a high probability of moderate to severe OSA. The use of opioids and OSA was associated with the greatest hazard of all-cause hospitalizations and MVC requiring hospital or ED visit. The interaction of opioids and OSA did not confer a synergistic risk for poor outcomes.
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23
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Lei Y, Li XX, Guo Z. Impact of timing of morphine treatment on infarct size in experimental animal model of acute myocardial ischemia and reperfusion. Eur J Pharmacol 2022; 928:175094. [PMID: 35714691 DOI: 10.1016/j.ejphar.2022.175094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
Morphine is generally used in clinical treatment for the patients who have not been effectively alleviated for chest pain after the treatment with nitrites or who contraindicate nitrite drugs. However, it was reported that the treatment with morphine in acute myocardial infarction or acute coronary artery syndromes induced increase in myocardial injury even increase of the mortality of the patients. After comparing the reported laboratory studies showing the cardioprotective effects and the clinical observations presenting the harmful consequences, we query whether the timing of the morphine treatment makes the difference in the prognosis of the ischemic/infarct myocardium. We found that intravenous injections of morphine (0.3 mg/kg) at 15 min before the acute myocardial ischemia, at 5 min and 20 min or 60 min after ligation of the coronary artery in separate groups of rats scheduled for acute myocardial ischemia, for 30 min or 90 min followed by reperfusion for 120 min, induced different results, reduction in the size of infarction, no effect and increases of the infarct sizes, respectively. The opioid μ- and kappa-receptors mediated the detrimental effect of morphine on the myocardial injury. The findings of this study suggest that administration of morphine may cause different consequences when used at different time in the pathology of acute myocardial ischemia and reperfusion. The underlying mechanisms in the pathology of acute myocardial ischemia warrant further study.
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Affiliation(s)
- Yi Lei
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China
| | - Xiao-Xi Li
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China; Department of Anaesthesia, Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, Shanxi, China
| | - Zheng Guo
- College of Anaesthesia, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China; Department of Anaesthesia, Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, 030001, Shanxi, China; Key Laboratory of Cellular Physiology (Shanxi Medical University), National Education Commission, Shanxi Medical University, 86 Xinjiannan Road, Taiyuan, 030001, Shanxi, China.
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Fernando H, McFadyen JD, Wang X, Shaw J, Stub D, Peter K. P2Y12 Antagonists in Cardiovascular Disease—Finding the Best Balance Between Preventing Ischemic Events and Causing Bleeding. Front Cardiovasc Med 2022; 9:854813. [PMID: 35647068 PMCID: PMC9133423 DOI: 10.3389/fcvm.2022.854813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022] Open
Abstract
Dual antiplatelet therapy comprising of aspirin and oral P2Y12 receptor antagonists are an established cornerstone of therapy in acute coronary syndromes and percutaneous coronary intervention. As a result, the platelet P2Y12 receptor remains a key therapeutic target in cardiovascular medicine since pharmacological antagonists were first developed in the 1990’s. With a greater understanding of platelet biology and the role played by the P2Y12 receptor in the amplification of platelet activation and thrombus formation, there has been progressive refinement in the development of P2Y12 receptor antagonists with greater potency and consistency of antiplatelet effect. However, challenges remain in the utilization of these agents particularly in balancing the need for greater protection from ischemic events whilst minimizing the bleeding risk and present a real opportunity for the institution of individualized medicine. Future drug developments will provide clinicians with greater avenues to achieve this.
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Affiliation(s)
- Himawan Fernando
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - James D. McFadyen
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiometabolic Health, University of Melbourne, Parkville, VIC, Australia
- Thrombosis and Hemostasis Unit, Department of Clinical Hematology, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Immunology, Monash University, Melbourne, VIC, Australia
| | - Xiaowei Wang
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiometabolic Health, University of Melbourne, Parkville, VIC, Australia
| | - James Shaw
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Dion Stub
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
- *Correspondence: Karlheinz Peter,
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Sex differences in prehospital analgesia in patients presenting with acute coronary syndromes and their association with clinical outcomes. Catheter Cardiovasc Interv 2022; 99:989-995. [DOI: 10.1002/ccd.30104] [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: 08/24/2021] [Revised: 12/28/2021] [Accepted: 01/13/2022] [Indexed: 11/07/2022]
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Roguin A, Kobo O, Meisel SR, Maraga E, Frimerman A, Amsalem N, Malka R, Levi Y, Fanne RA. Morphine Use in ST-Elevation Myocardial Infarction With Downstream P 2Y 12 Receptor Blockers-Insight From Observational Study. J Cardiovasc Pharmacol Ther 2022; 27:10742484221107793. [PMID: 35861488 DOI: 10.1177/10742484221107793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Morphine use for patients presenting with NSTE-ACS is associated with excess mortality. However, the role of morphine in STE-ACS is ill characterized. We have recently confirmed direct prothrombotic effect of morphine using murine models. We sought to explore whether morphine use in STE-ACS patients, used to be scheduled for downstream P2Y12 blockers, is negatively associated with procedural and clinical outcomes. METHODS A single-center, observational retrospective analysis enrolling 130 non-randomized stable patients sustaining STE-ACS as their first manifestation of coronary disease, who presented between December 2010 and June 2013. All were managed by early invasive approach. Of study patients, 55 were treated by morphine, and 75 were not. All were administered downstream P2Y12 blockers according to an already abandoned local policy. Outcomes evaluated included TIMI grade flow, thrombus burden, ST-segment resolution, myocardial function by echocardiography, and cardiovascular death. RESULTS Morphine administration was associated with a significantly higher incidence of impaired final TIMI grade flow (TIMI < 3, 40% vs 4%, P < .05), lower incidence of ST-segment resolution >70% (40.7% vs 76.5%, P < .05), and a higher incidence of moderate or severe systolic dysfunction (48.1% vs 29.1%, P < .05) compared with morphine naive patients. Interestingly, the overall mortality rate was higher in the morphine-treated group (18% vs 5.3%, P < .05). CONCLUSIONS AND RELEVANCE Morphine administration combined with the downstream P2Y12 blockers practice signify a group with a higher occurrence of impaired myocardial reperfusion and cardiovascular death despite established on-time primary angioplasty.
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Affiliation(s)
- Ariel Roguin
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
| | - Ofer Kobo
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
| | - Simcha Ron Meisel
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
| | - Emad Maraga
- Department of Clinical Biochemistry, 58884Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Aaron Frimerman
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
| | - Naama Amsalem
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
| | - Rinat Malka
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
| | - Yaniv Levi
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
| | - Rami Abu Fanne
- Department of Cardiology, 26736Hillel Yaffe Medical Center, Hadera, Haifa, Israel
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27
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Fernando H, Nehme Z, Peter K, Bernard S, Stephenson M, Bray JE, Myles PS, Stub R, Cameron P, Ellims AH, Taylor AJ, Kaye DM, Smith K, Stub D. Association between pre-hospital chest pain severity and myocardial injury in ST elevation myocardial infarction: A post-hoc analysis of the AVOID study. IJC HEART & VASCULATURE 2021; 37:100899. [PMID: 34815999 PMCID: PMC8591354 DOI: 10.1016/j.ijcha.2021.100899] [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: 09/30/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 12/04/2022]
Abstract
Background We sought to determine if an association exists between prehospital chest pain severity and markers of myocardial injury. Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. The primary endpoint was the association of pre-hospital initial chest pain severity, cardiac biomarkers and infarct size based on cardiac magnetic resonance imaging. Groups were categorized based on moderate to severe chest pain (numerical rating scale pain ≥ 5/10) or less than moderate severity to compare procedural and clinical outcomes. 414 patients were included in the analysis. There was a weak correlation between initial pre-hospital chest pain severity and peak creatine kinase (r = 0.16, p = 0.001) and peak cardiac troponin I (r = 0.14, p = 0.005). Both were no longer significant after adjusting for known confounders. There was no association between moderate to severe chest pain on arrival and major adverse cardiac events at 6 months (20% vs. 14%, p=0.12). There was a weak correlation between history of ischemic heart disease (r = 0.16, p = 0.001), percutaneous coronary intervention (r = 0.16, p = 0.001), left anterior descending artery (r = 0.12, p = 0.012) as the culprit vessel and a weak negative correlation between age (r = -0.14, p = 0.039) and chest pain. Conclusion Only a weak association between pre-hospital chest pain severity and markers of myocardial injury was identified, supporting more judicious use of opioid analgesia with a focus on patient comfort.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Stephen Bernard
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael Stephenson
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Janet E. Bray
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Paul S. Myles
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Anaesthesiology and Perioperative Medicine, The Alfred and Monash University, Australia
| | - Romi Stub
- Department of Anaesthesiology and Perioperative Medicine, The Alfred and Monash University, Australia
| | - Peter Cameron
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | - David M. Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Department of Cardiology, Western Health, Melbourne, Australia
- Corresponding author at: Heart Centre, Level 3, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia.
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28
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Fernando H, Duong T, Huynh K, Noonan J, Shaw J, Duffy SJ, Nehme Z, Smith K, Myles PS, Meikle PJ, Peter K, Stub D. Effects of lignocaine vs. opioids on antiplatelet activity of ticagrelor: the LOCAL trial. Eur Heart J 2021; 42:4025-4036. [PMID: 34423354 DOI: 10.1093/eurheartj/ehab557] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/09/2021] [Accepted: 08/02/2021] [Indexed: 12/12/2022] Open
Abstract
AIMS We assessed the impact of intravenous fentanyl and lignocaine on the pharmacokinetics and pharmacodynamics of ticagrelor in patients with unstable angina and non-ST-elevation myocardial infarction and their procedural analgesic efficacy and safety. METHODS AND RESULTS Seventy patients undergoing coronary angiography with ticagrelor loading were included in the pharmacokinetic and pharmacodynamic analyses of this randomized trial. Plasma ticagrelor levels 2 h post-loading dose were significantly lower in the fentanyl arm than in the lignocaine treatment arm (598 vs. 1008 ng/mL, P = 0.014). The area under the plasma-time curves for ticagrelor (1228 vs. 2753 ng h/mL, P < 0.001) and its active metabolite (201 vs. 447 ng h/mL, P = 0.001) were both significantly lower in the fentanyl arm. Expression of activated platelet glycoprotein IIb/IIIa receptor (2829 vs. 1426 mean fluorescence intensity, P = 0.006) and P-selectin (439 vs. 211 mean fluorescence intensity, P = 0.001) was significantly higher at 60 min in the fentanyl arm. A higher proportion of patients had high on-treatment platelet reactivity in the fentanyl arm at 60 min using the Multiplate Analyzer (41% vs. 9%, P = 0.002) and 120 min using the VerifyNow (30% vs. 3%, P = 0.003) and VASP (37% vs. 6%, P = 0.002) assays. Both drugs were well tolerated with a high level of patient satisfaction. CONCLUSIONS Unlike fentanyl, lignocaine does not impair the bioavailability or delay the antiplatelet effect of ticagrelor. Both drugs were well tolerated and effective with a high level of patient satisfaction for procedural analgesia. Routine procedural analgesia during percutaneous coronary intervention should be reconsidered and if performed, lignocaine is a beneficial alternative to fentanyl.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Cardiology, Bendigo Health, 100 Barnard St, Bendigo, Victoria 3550, Australia
| | - Thy Duong
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia
| | - Kevin Huynh
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia
| | - Jonathan Noonan
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Department of Cardiometabolic Health, University of Melbourne, 75 Commercial Road, Melbourne, Victoria 3004, Australia
| | - James Shaw
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road Melbourne, Melbourne, Victoria 3004, Australia
| | - Ziad Nehme
- Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Centre for Research and Evaluation, Ambulance Victoria, PO Box 2000, Doncaster, Victoria 3108, Australia
| | - Karen Smith
- Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Centre for Research and Evaluation, Ambulance Victoria, PO Box 2000, Doncaster, Victoria 3108, Australia
| | - Paul S Myles
- Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred and Monash University, 55 Commercial Road Melbourne, Melbourne, Victoria 3004, Australia
| | - Peter J Meikle
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Cardiometabolic Health, University of Melbourne, 75 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Department of Cardiometabolic Health, University of Melbourne, 75 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Cardiology, Western Health, 176 Furlong Rd, St Albans, Victoria 3021, Australia
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Chow SL, Sasson C, Benjamin IJ, Califf RM, Compton WM, Oliva EM, Robson C, Sanchez EJ. Opioid Use and Its Relationship to Cardiovascular Disease and Brain Health: A Presidential Advisory From the American Heart Association. Circulation 2021; 144:e218-e232. [PMID: 34407637 DOI: 10.1161/cir.0000000000001007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The misuse of opioids continues to be epidemic, resulting in dependency and a recent upsurge in drug overdoses that have contributed to a significant decrease in life expectancy in the United States. Moreover, recent data suggest that commonly used opioids for the management of pain may produce undesirable pharmacological actions and interfere with critical medications commonly used in cardiovascular disease and stroke; however, the impact on outcomes remains controversial. The American Heart Association developed an advisory statement for health care professionals and researchers in the setting of cardiovascular and brain health to synthesize the current literature, to provide approaches for identifying patients with opioid use disorder, and to address pain management and overdose. A literature and internet search spanning from January 1, 2012, to February 15, 2021, and limited to epidemiology studies, reviews, consensus statements, and guidelines in human subjects was conducted. Suggestions and considerations listed in this document are based primarily on published evidence from this review whenever possible, as well as expert opinion. Several federal and institutional consensus documents and clinical resources are currently available to both patients and clinicians; however, none have specifically addressed cardiovascular disease and brain health. Although strategic tools and therapeutic approaches for recognition of opioid use disorder and safe opioid use are available for health care professionals who manage patients with cardiovascular disease and stroke, high-quality evidence does not currently exist. Therefore, there is an urgent need for more research to identify the most effective approaches to improve care for these patients.
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Cardiovascular Complications of Opioid Use: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:205-223. [PMID: 33446314 DOI: 10.1016/j.jacc.2020.11.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022]
Abstract
Opioids are the most potent of all analgesics. Although traditionally used solely for acute self-limited conditions and palliation of severe cancer-associated pain, a movement to promote subjective pain (scale, 0 to 10) to the status of a "fifth vital sign" bolstered widespread prescribing for chronic, noncancer pain. This, coupled with rising misuse, initiated a surge in unintentional deaths, increased drug-associated acute coronary syndrome, and endocarditis. In response, the American College of Cardiology issued a call to action for cardiovascular care teams. Opioid toxicity is primarily mediated via potent μ-receptor agonism resulting in ventilatory depression. However, both overdose and opioid withdrawal can trigger major adverse cardiovascular events resulting from hemodynamic, vascular, and proarrhythmic/electrophysiological consequences. Although natural opioid analogues are devoid of repolarization effects, synthetic agents may be proarrhythmic. This perspective explores cardiovascular consequences of opioids, the contributions of off-target electrophysiologic properties to mortality, and provides practical safety recommendations.
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Kunkel KJ, Lemor A, Mahmood S, Villablanca P, Ramakrishna H. 2021 Update for the Diagnosis and Management of Acute Coronary Syndromes for the Perioperative Clinician. J Cardiothorac Vasc Anesth 2021; 36:2767-2779. [PMID: 34400062 PMCID: PMC8297970 DOI: 10.1053/j.jvca.2021.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
In this review, recent key publications related to acute coronary syndrome (ACS) are summarized and placed into context of contemporary practice. Landmark trials examining vascular access in ST-elevation myocardial infarction, the management of multivessel disease, acute myocardial infarction and cardiac arrest are discussed. An update in pharmacology for ACS provides updates in major trials relating to P2Y12 inhibitor initiation, deescalation, and use in special populations. Additional updates in the use of lipid-lowering agents and adjunctive medications in ACS are reviewed. Finally, cardiac pathology related to coronavirus disease 2019 (COVID-19), as well as the impact of the COVID-19 global pandemic on the care of patients with ACS, is summarized.
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Affiliation(s)
| | - Alejandro Lemor
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Shazil Mahmood
- Division of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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Zhang Y, Hui J, Chen X. Preprocedural Ticagrelor Treatment was Associated with Improved Early Reperfusion and Reduced Short-term Heart Failure in East-Asian ST-segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention. Int J Gen Med 2021; 14:1927-1938. [PMID: 34040425 PMCID: PMC8140910 DOI: 10.2147/ijgm.s307404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this monocentric retrospective observational study is to investigate whether a loading dose of ticagrelor treatment before percutaneous coronary intervention (PCI) procedure improves the early reperfusion and short-term heart function in East-Asian ST segment elevation myocardial infarction (STEMI) patients. Patients and Methods The study included 326 STEMI patients undergoing primary PCI in Jiading Central Hospital. One hundred and forty patients received a loading dose of ticagrelor before entering the catheter laboratory. One hundred and eighty-six patients received a loading dose of ticagrelor in the catheter laboratory before the initiation of PCI. Reperfusion endpoints included the presence of self-patency in the culprit artery, the ST-segment elevation resolution over 50% within 24 h after PCI, and the presence of no-reflow in the culprit artery. Clinical endpoints included all-cause mortality, new-onset heart failure, reinfarction and stent thrombosis within 28 days after PCI. Secondary clinical endpoints included mechanical complications and bleeding events. Results In comparison with the in-lab treatment group, the preprocedural treatment group had a significant higher proportion of self-patency in the culprit artery (25.71% vs 16.67%, P=0.045) and early ST-segment elevation resolution (48.57% vs 27.96%, P<0.001). Preprocedural ticagrelor treatment was associated with a significant reduction of new-onset heart failure (9.29% vs 18.82%, p=0.016). Stent thrombosis risks were numerically reduced in the preprocedural treatment group (0.71% vs 1.61%, P=0.466). The rates of major cardiovascular adverse events, reinfarctions and mortality did not differ between the two groups. Bleeding events in the preprocedural treatment group was notn significantly higher than the in-lab treatment group (4.39% vs 1.39%, P=0.142). Conclusion Preprocedural administration of a loading dose of ticagrelor was associated with improved early reperfusion and reduced short-term heart failure in East-Asian STEMI patients undergoing primary PCI, but care should be taken for excess bleeding events.
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Affiliation(s)
- Yunke Zhang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China.,Department of Cardiology, Shanghai University of Medicine and Health Sciences Affiliated Jiading Central Hospital, Shanghai, 201800, People's Republic of China
| | - Jie Hui
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Xia Chen
- Department of Cardiology, Shanghai University of Medicine and Health Sciences Affiliated Jiading Central Hospital, Shanghai, 201800, People's Republic of China
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Stiermaier T, Schaefer P, Meyer-Saraei R, Saad M, de Waha-Thiele S, Pöss J, Fuernau G, Graf T, Kurz T, Frydrychowicz A, Barkhausen J, Desch S, Thiele H, Eitel I. Impact of Morphine Treatment With and Without Metoclopramide Coadministration on Myocardial and Microvascular Injury in Acute Myocardial Infarction: Insights From the Randomized MonAMI Trial. J Am Heart Assoc 2021; 10:e018881. [PMID: 33899498 PMCID: PMC8200763 DOI: 10.1161/jaha.120.018881] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Intravenous morphine administration can adversely affect platelet inhibition induced by P2Y12 receptor inhibitors after acute myocardial infarction. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. The aim of this prospective, randomized MonAMI (Impact of Morphine Treatment With and Without Metoclopramide Coadministration on Platelet Inhibition in Acute Myocardial Infarction) trial was, therefore, to investigate the impact of morphine with or without metoclopramide coadministration on myocardial and microvascular injury. Methods and Results Patients with acute myocardial infarction (n=138) were assigned in a 1:1:1 ratio to ticagrelor 180 mg plus: (1) intravenous morphine 5 mg (morphine group); (2) intravenous morphine 5 mg and metoclopramide 10 mg (morphine+metoclopramide group); or (3) intravenous placebo (control group) administered before primary percutaneous coronary intervention. Cardiac magnetic resonance imaging was performed in 104 patients on day 1 to 4 after the index event. Infarct size was significantly smaller in the morphine only group as compared with controls (percentage of left ventricular mass, 15.5 versus 17.9; P=0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (28% versus 54%; P=0.022) and the extent of microvascular obstruction was smaller (percentage of left ventricular mass, 0 versus 0.74; P=0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio, 0.37; 95% CI, 0.14–0.93 [P=0.035]). There was no significant difference in infarct size (P=0.491) and extent (P=0.753) or presence (P=0.914) of microvascular obstruction when comparing the morphine+metoclopramide group with the control group. Conclusions In this randomized study, intravenous administration of morphine before primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following acute myocardial infarction. This effect was not observed in the morphine plus metoclopramide group. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02627950.
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Affiliation(s)
- Thomas Stiermaier
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Philipp Schaefer
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Roza Meyer-Saraei
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Mohammed Saad
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Suzanne de Waha-Thiele
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Janine Pöss
- Department of Internal Medicine/Cardiology and Leipzig Heart Institute Heart Center Leipzig at University of Leipzig Germany
| | - Georg Fuernau
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Tobias Graf
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Thomas Kurz
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
| | - Alex Frydrychowicz
- Department of Radiology and Nuclear Medicine University Hospital Schleswig-Holstein Lübeck Germany
| | - Jörg Barkhausen
- Department of Radiology and Nuclear Medicine University Hospital Schleswig-Holstein Lübeck Germany
| | - Steffen Desch
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany.,Department of Internal Medicine/Cardiology and Leipzig Heart Institute Heart Center Leipzig at University of Leipzig Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology and Leipzig Heart Institute Heart Center Leipzig at University of Leipzig Germany
| | - Ingo Eitel
- Medical Clinic II University Heart Center Lübeck Lübeck Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck Lübeck Germany
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Fernando H, Milne C, Nehme Z, Ball J, Bernard S, Stephenson M, Myles PS, Bray JE, Lefkovits J, Liew D, Peter K, Brennan A, Dinh D, Andrew E, Taylor AJ, Smith K, Stub D. An open-label, non-inferiority randomized controlled trial of lidocAine Versus Opioids In MyocarDial Infarction study (AVOID-2 study) methods paper. Contemp Clin Trials 2021; 105:106411. [PMID: 33894363 DOI: 10.1016/j.cct.2021.106411] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 02/07/2023]
Abstract
Background There is increasing evidence that opioids interfere with the oral bioavailability of P2Y12 inhibitors leading to delayed onset of antiplatelet effects. Several strategies have been proposed to mitigate this interaction including utilizing alternative analgesic agents in the management of ischemic chest pain. Methods The lidocAine Versus Opioids In MyocarDial Infarction (AVOID-2) study is a phase II, pre-hospital, open-label, non-inferiority, randomized controlled trial conducted by Ambulance Victoria and Monash University in metropolitan Melbourne, Victoria, Australia. The purpose of the study is to compare the analgesic effect (reduction in pain by arrival to hospital) and safety (e.g. adverse drug reactions) (co-primary endpoints) of intravenous lidocaine versus intravenous fentanyl in 300 adult patients attended by ambulance with suspected ST-elevation myocardial infarction (STEMI). Secondary endpoints and a cardiac magnetic resonance imaging (MRI) sub-study will also compare infarct size between these two groups. Conclusions The evaluation of alternative analgesic agents in the management of acute coronary syndromes is urgently needed to manage the opioid-P2Y12 inhibitor interaction. The results of this trial will have significant implications on the emergency management of acute coronary syndromes internationally.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Catherine Milne
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Jocasta Ball
- Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Stephen Bernard
- Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Michael Stephenson
- Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Paul S Myles
- Monash University, Melbourne, Australia; Department of Anesthesiology and Perioperative Medicine, The Alfred and Monash University, Australia
| | | | - Jeffrey Lefkovits
- Monash University, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia
| | | | - Diem Dinh
- Monash University, Melbourne, Australia
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Andrew J Taylor
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Karen Smith
- Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia; Department of Cardiology, Western Health, Melbourne, Australia.
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Ranka S, Dalia T, Acharya P, Taduru SS, Pothuru S, Mahmood U, Stack B, Shah Z, Gupta K. Comparison of Hospitalization Trends and Outcomes in Acute Myocardial Infarction Patients With Versus Without Opioid Use Disorder. Am J Cardiol 2021; 145:18-24. [PMID: 33454349 DOI: 10.1016/j.amjcard.2020.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 11/18/2022]
Abstract
Discrepancies in medical care are well known to adversely affect patients with opioid abuse disorders (OUD), including management and outcomes of acute myocardial infarction (AMI) in patients with OUD. We used the National Inpatient Sample was queried from January 2006 to September 2015 to identify all patients ≥18 years admitted with a primary diagnosis of AMI (weighted N = 13,030; unweighted N = 2,670) and concomitant OUD. Patients using other nonopiate illicit drugs were excluded. Propensity matching (1:1) yielded 2,253 well-matched pairs in which intergroup comparison of invasive revascularization strategies and cardiac outcomes were performed. The prevalence of OUD patients with AMI over the last decade has doubled, from 163 (2006) to 326 cases (2015) per 100,000 admissions for AMI. The OUD group underwent less cardiac catheterization (63.2% vs 72.2%; p <0.001), percutaneous coronary intervention (37.0% vs 48.5%; p <0.001) and drug-eluting stent placement (32.3% vs 19.5%; p <0.001) compared with non-OUD. No differences in in-hospital mortality/cardiogenic shock were noted. Among subgroup of ST-elevation myocardial infarction patients (26.2% of overall cohort), the OUD patients were less likely to receive percutaneous coronary intervention (67.9% vs 75.5%; p = 0.002), drug-eluting stent (31.4% vs 47.9%; p <0.001) with a significantly higher mortality (7.4% vs 4.3%), and cardiogenic shock (11.7% vs 7.9%). No differences in the frequency of coronary bypass grafting were noted in AMI or its subgroups. In conclusion, OUD patients presenting with AMI receive less invasive treatment compared with those without OUD. OUD patients presenting with ST-elevation myocardial infarction have worse in-hospital outcomes with increased mortality and cardiogenic shock.
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Affiliation(s)
- Sagar Ranka
- Department of Cardiovascular Medicine, The University of Kansas Health System, University of Kansas School of Medicine, Kansas City, Kansas
| | - Tarun Dalia
- Department of Cardiovascular Medicine, The University of Kansas Health System, University of Kansas School of Medicine, Kansas City, Kansas
| | - Prakash Acharya
- Department of Cardiovascular Medicine, The University of Kansas Health System, University of Kansas School of Medicine, Kansas City, Kansas
| | - Siva Sagar Taduru
- Department of Cardiovascular Medicine, The University of Kansas Health System, University of Kansas School of Medicine, Kansas City, Kansas
| | | | - Uzair Mahmood
- Department of Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Brianna Stack
- Kansas University School of Medicine, Kansas City, Kansas
| | - Zubair Shah
- Department of Cardiovascular Medicine, The University of Kansas Health System, University of Kansas School of Medicine, Kansas City, Kansas
| | - Kamal Gupta
- Department of Cardiovascular Medicine, The University of Kansas Health System, University of Kansas School of Medicine, Kansas City, Kansas.
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Jalali Z, Khademalhosseini M, Soltani N, Esmaeili Nadimi A. Smoking, alcohol and opioids effect on coronary microcirculation: an update overview. BMC Cardiovasc Disord 2021; 21:185. [PMID: 33858347 PMCID: PMC8051045 DOI: 10.1186/s12872-021-01990-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 04/07/2021] [Indexed: 02/07/2023] Open
Abstract
Smoking, heavy alcohol drinking and drug abuse are detrimental lifestyle factors leading to loss of million years of healthy life annually. One of the major health complications caused by these substances is the development of cardiovascular diseases (CVD), which accounts for a significant proportion of substance-induced death. Smoking and excessive alcohol consumption are related to the higher risk of acute myocardial infarction. Similarly, opioid addiction, as one of the most commonly used substances worldwide, is associated with cardiac events such as ischemia and myocardial infarction (MI). As supported by many studies, coronary artery disease (CAD) is considered as a major cause for substance-induced cardiac events. Nonetheless, over the last three decades, a growing body of evidence indicates that a significant proportion of substance-induced cardiac ischemia or MI cases, do not manifest any signs of CAD. In the absence of CAD, the coronary microvascular dysfunction is believed to be the main underlying reason for CVD. To date, comprehensive literature reviews have been published on the clinicopathology of CAD caused by smoking and opioids, as well as macrovascular pathological features of the alcoholic cardiomyopathy. However, to the best of our knowledge there is no review article about the impact of these substances on the coronary microvascular network. Therefore, the present review will focus on the current understanding of the pathophysiological alterations in the coronary microcirculation triggered by smoking, alcohol and opioids.
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Affiliation(s)
- Zahra Jalali
- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Building Number 1, Emam Ali Boulevard, P.O. Box: 77175-835, 7719617996, Rafsanjan, Iran
- Department of Clinical Biochemistry, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Morteza Khademalhosseini
- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Building Number 1, Emam Ali Boulevard, P.O. Box: 77175-835, 7719617996, Rafsanjan, Iran
- Department of Pathology, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Narjes Soltani
- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Building Number 1, Emam Ali Boulevard, P.O. Box: 77175-835, 7719617996, Rafsanjan, Iran
| | - Ali Esmaeili Nadimi
- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Building Number 1, Emam Ali Boulevard, P.O. Box: 77175-835, 7719617996, Rafsanjan, Iran.
- Department of Cardiology, School of Medicine, Rafsanjani University of Medical Sciences, Rafsanjan, Iran.
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38
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Senguttuvan NB, Suman F, Paneerselvam T, Malepati B, Ramesh S, Vallivedu MV, Badimela P, Ramadoss M, Iyer M, Krishnamurthy P, Vinod Kumar B, Balasubramaniyan JV, Sadhanandham S, Jebaraj R, Manokar P, Muralidharan TR, Murthy JS, Thanikachalam S, Krishnamoorthy P, Baber U, Karthikeyan G. Comparison of the effect of Morphine and Fentanyl in patients with acute coronary syndrome receiving Ticagrelor - The COMET (Comparison Morphine, Fentayl and Ticagrelor) randomized controlled trial. Int J Cardiol 2021; 330:1-6. [PMID: 33600846 DOI: 10.1016/j.ijcard.2021.02.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) remains the cornerstone of acute coronary syndrome (ACS) management, and ticagrelor is one of the commonly used second antiplatelet agents. There is some evidence to suggest that morphine may reduce the antiplatelet effect of ticagrelor. METHODS AND RESULTS In a single-center, randomized controlled trial, we compared the effect of morphine and fentanyl on platelet aggregation (PA) among patients with ACS treated with ticagrelor. Platelet aggregation was studied by automated light transmittance aggregometry (LTA) at baseline, and at 2 h after ticagrelor loading. The primary outcome was the difference in the maximal inhibition of platelet aggregation [IPA(%)] between the groups at 2 h. Pain relief, and drug-related adverse events were secondary outcomes. Of 136 patients randomized, 70 received fentanyl and 66 received morphine. At baseline, the median (IQR) platelet aggregation [61.35% (54.6 to 70) Vs. 58.8% (52.7 to 72.9)] were comparable between the groups. There was no statistically significant difference between the fentanyl and the morphine groups in IPA at 2-h [85.88%(64.65-98.16) and 81.93%(44.2-98.03), p = 0.09]. However, morphine use was independently associated with a PA of >30% at 2 h (p < 0.009). There was no difference in adverse events. CONCLUSION In patients with ACS, there was no significant difference between the use of fentanyl or morphine on the effect of ticagrelor on PA. (CTRI/2018/04/013423).
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Affiliation(s)
- Nagendra Boopathy Senguttuvan
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India; Adjunct Faculty, Department of Engineering and design, Indian Institute of Technology-Madras, Chennai, India.
| | - Febe Suman
- Department of Pathology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - TamilAnbu Paneerselvam
- Department of Emergency Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Balakrishna Malepati
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Sankaran Ramesh
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Mano Vikash Vallivedu
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Phalgun Badimela
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Mahalakshmi Ramadoss
- Faculty of Clinical Research, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Meena Iyer
- Faculty of Clinical Research, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Preetam Krishnamurthy
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Balakrishnan Vinod Kumar
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Jayanthy Venkata Balasubramaniyan
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Shanmugasundram Sadhanandham
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Rathinasamy Jebaraj
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Panchanatham Manokar
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Thoddi Ramamurthy Muralidharan
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Jayanthy Sathyanarayana Murthy
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Sadagopan Thanikachalam
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), No.1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu 600116, India
| | - Parasuram Krishnamoorthy
- Division of Interventional Cardiology, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York 10029, United States of America
| | - Usman Baber
- Division of Interventional cardiology, Cardiovascular Institute - Suite 2E, Oklahoma University, 825 N.E. 10th St., Oklahoma City, OK 73104, United States of America
| | - Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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Dehe L, Shaqura M, Nordine M, Habazettl H, von Kwiatkowski P, Schluchter H, Shakibaei M, Mousa SA, Schäfer M, Treskatsch S. Chronic Naltrexone Therapy Is Associated with Improved Cardiac Function in Volume Overloaded Rats. Cardiovasc Drugs Ther 2021; 35:733-743. [PMID: 33484395 PMCID: PMC8266787 DOI: 10.1007/s10557-020-07132-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Myocardial opioid receptors were demonstrated in animals and humans and seem to colocalize with membranous and sarcolemmal calcium channels of the excitation-contraction coupling in the left ventricle (LV). Therefore, this study investigated whether blockade of the cardiac opioid system by naltrexone would affect cardiac function and neurohumoral parameters in Wistar rats with volume overload-induced heart failure. METHODS Volume overload in Wistar rats was induced by an aortocaval fistula (ACF). Left ventricular cardiac opioid receptors were identified by immunohistochemistry and their messenger ribonucleic acid (mRNA) as well as their endogenous ligand mRNA quantified by real-time polymerase chain reaction (RT-PCR). Following continuous delivery of either the opioid receptor antagonist naltrexone or vehicle via minipumps (n = 5 rats each), hemodynamic and humoral parameters were assessed 28 days after ACF induction. Sham-operated animals served as controls. RESULTS In ACF rats mu-, delta-, and kappa-opioid receptors colocalized with voltage-gated L-type Ca2+ channels in left ventricular cardiomyocytes. Chronic naltrexone treatment of ACF rats reduced central venous pressure (CVP) and left ventricular end-diastolic pressure (LVEDP), and improved systolic and diastolic left ventricular functions. Concomitantly, rat brain natriuretic peptide (rBNP-45) and angiotensin-2 plasma concentrations which were elevated during ACF were significantly diminished following naltrexone treatment. In parallel, chronic naltrexone significantly reduced mu-, delta-, and kappa-opioid receptor mRNA, while it increased the endogenous opioid peptide mRNA compared to controls. CONCLUSION Opioid receptor blockade by naltrexone leads to improved LV function and decreases in rBNP-45 and angiotensin-2 plasma levels. In parallel, naltrexone resulted in opioid receptor mRNA downregulation and an elevated intrinsic tone of endogenous opioid peptides possibly reflecting a potentially cardiodepressant effect of the cardiac opioid system during volume overload.
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Affiliation(s)
- Lukas Dehe
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Mohammed Shaqura
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Michael Nordine
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Helmut Habazettl
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Physiology Campus Charité Mitte, Chariteplatz 1, 10117, Berlin, Germany
| | - Petra von Kwiatkowski
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Helena Schluchter
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Mehdi Shakibaei
- Institute of Anatomy, Ludwig-Maximilians-Universität München, Pettenkoferstraße 11, 80336, Munich, Germany
| | - Shaaban A Mousa
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Michael Schäfer
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Sascha Treskatsch
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Fernando H, Shaw JA, Myles PS, Peter K, Stub D. The opioid-P2Y12 inhibitor interaction: Potential strategies to mitigate the interaction and consideration of alternative analgesic agents in myocardial infarction. Pharmacol Ther 2021; 217:107665. [DOI: 10.1016/j.pharmthera.2020.107665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/13/2020] [Indexed: 01/04/2023]
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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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Abu Fanne R, Maraga E, Meisel SR, Maanit S, Abdeen S, Roguin A, Higazi AA. Morphine directly promotes thrombus formation in murine models of vascular thrombosis: A call for revisiting basic tenets. Thromb Res 2020; 193:204-206. [PMID: 32768703 DOI: 10.1016/j.thromres.2020.07.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/10/2020] [Accepted: 07/24/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Rami Abu Fanne
- Department of Cardiology, Hillel Yaffe Medical Center, Israel; Department of Clinical Biochemistry, Hadassah Hebrew University Hospital, Jerusalem, Israel.
| | - Emad Maraga
- Department of Clinical Biochemistry, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | - Shapira Maanit
- Clinical Biochemistry & Hematology Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Suhair Abdeen
- Department of Clinical Biochemistry, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ariel Roguin
- Department of Cardiology, Hillel Yaffe Medical Center, Israel
| | - Abd-Alroof Higazi
- Department of Clinical Biochemistry, Hadassah Hebrew University Hospital, Jerusalem, Israel
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Abstract
PURPOSE OF REVIEW Acute coronary syndrome is a major health problem affecting ~ 1.5 million individuals a year in the USA. We review the contemporary role of anti-anginal and anti-ischemic therapies in the management of an individual presenting with an acute coronary syndrome. RECENT FINDINGS Early diagnosis and appropriate evidence-based therapies significantly improve clinical outcomes in acute coronary syndrome patients. Typically, acute coronary syndrome is associated with rupture of an atherosclerotic plaque and either partial or complete thrombotic occlusion of a coronary artery. Management of an acute coronary syndrome is targeted towards this underlying pathophysiology. The last few years have seen significant advances in anti-anginal and anti-ischemic therapies in the management of patients with acute coronary syndrome. It is important to have a team effort to target risk reduction measures and to emphasize medication and dietary compliance. Long-term pharmacotherapy should include aspirin, beta-blocker, DAPT (for at least 1 year), statins, and ACE inhibitors and PCSK9 inhibitors if indicated.
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Affiliation(s)
- Abhizith Deoker
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, 4800 Alberta Avenue, El Paso, TX, 79905, USA
| | - Angelica Lehker
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, 4800 Alberta Avenue, El Paso, TX, 79905, USA
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
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Furtado RHM, Nicolau JC, Guo J, Im K, White JA, Sabatine MS, Newby LK, Giugliano RP. Morphine and Cardiovascular Outcomes Among Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Undergoing Coronary Angiography. J Am Coll Cardiol 2020; 75:289-300. [PMID: 31976867 DOI: 10.1016/j.jacc.2019.11.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/02/2019] [Accepted: 11/04/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mechanistic studies have shown that morphine blunts the antiplatelet effects of oral adenosine diphosphate receptor blockers. However, the clinical relevance of this interaction is controversial. OBJECTIVES This study sought to explore the association between morphine and ischemic events in 5,438 patients treated with concomitant clopidogrel presenting with non-ST-segment elevation acute coronary syndromes (NSTEACS) in the EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome) trial. Patients not treated with clopidogrel (n = 3,462) were used as negative controls. METHODS Endpoints were the composite of death, myocardial infarction (MI), recurrent ischemia, or thrombotic bailout at 96 h (4-way endpoint) and the composite of death or MI at 30 days. RESULTS In patients treated with clopidogrel, morphine use was associated with higher rates of the 4-way endpoint at 96 h (adjusted odds ratio [OR]: 1.40; 95% confidence interval [CI]: 1.04 to 1.87; p = 0.026). There was a trend for higher rates of death or MI at 30 days (adjusted OR: 1.29; 95% CI: 0.98 to 1.70; p = 0.072), driven by events in the first 48 h (adjusted hazard ratio: 1.54; 95% CI: 1.07 to 2.23; p = 0.021). In patients not treated with clopidogrel, morphine was not associated with either the 4-way endpoint at 96 h (adjusted OR: 1.05; 95% CI: 0.74 to 1.49; p = 0.79; pinteraction = 0.36 ) or death or MI at 30 days (adjusted OR: 1.07; 95% CI: 0.77 to 1.48; p = 0.70; pinteraction = 0.46). CONCLUSIONS When used concomitantly with clopidogrel pre-treatment, morphine was associated with higher rates of ischemic events in patients with NSTEACS. (EARLY ACS: Early Glycoprotein IIb/IIIa Inhibition in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome; NCT00089895).
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Affiliation(s)
- Remo H M Furtado
- Thrombosis In Myocardial Infarction Study Group-Brigham and Women's Hospital, Boston, Massachusetts; Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jianping Guo
- Thrombosis In Myocardial Infarction Study Group-Brigham and Women's Hospital, Boston, Massachusetts
| | - Kyungah Im
- Thrombosis In Myocardial Infarction Study Group-Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Marc S Sabatine
- Thrombosis In Myocardial Infarction Study Group-Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Robert P Giugliano
- Thrombosis In Myocardial Infarction Study Group-Brigham and Women's Hospital, Boston, Massachusetts.
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Sridharan A, Kimmelstiel C. Morphine in primary percutaneous coronary intervention-No pain, questionable gain. Catheter Cardiovasc Interv 2020; 96:89-90. [PMID: 32652843 DOI: 10.1002/ccd.29091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/08/2022]
Abstract
The clinical impact of concurrently administered morphine and P2Y12 inhibitors in primary percutaneous coronary intervention (PCI) is not well understood. Large, randomized clinical trials are required to assess clinical outcomes with concurrent morphine and P2Y12 inhibitor use in ST-segment elevation myocardial infarction patients undergoing PCI. Based on the currently available pharmacologic data, cautious use of morphine in primary PCI would seem prudent.
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Affiliation(s)
- Aadhavi Sridharan
- Division of Cardiology and Cardiac Catheterization Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Carey Kimmelstiel
- Division of Cardiology and Cardiac Catheterization Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
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46
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Fernando H, Nehme Z, Peter K, Bernard S, Stephenson M, Bray J, Cameron P, Ellims A, Taylor A, Kaye DM, Smith K, Stub D. Prehospital opioid dose and myocardial injury in patients with ST elevation myocardial infarction. Open Heart 2020; 7:e001307. [PMID: 32719075 PMCID: PMC7380835 DOI: 10.1136/openhrt-2020-001307] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/18/2020] [Accepted: 05/27/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To characterise the relationship between opioid dose and myocardial infarct size in patients with ST elevation myocardial infarction (STEMI). METHODS Patients given opioid treatment by emergency medical services with confirmed STEMI were included in this secondary, retrospective cohort analysis of the Air versus Oxygen in Myocardial Infarction (AVOID) study. Patients with cardiogenic shock were excluded. The primary endpoint was comparison of cardiac biomarkers as a measure of infarct size based on opioid dose (low ≤8.75 mg, intermediate 8.76-15 mg and high >15 mg of intravenous morphine equivalent dose). RESULTS 422 patients were included in the analysis. There was a significantly higher proportion of patients with Thrombolysis in Myocardial Infarction (TIMI) 0 or 1 flow pre-percutaneous coronary intervention (PCI) (94% vs 81%, p=0.005) and greater use of thrombus aspiration catheters (59% vs 30%, p<0.001) in the high compared with low-dose opioid group. After adjustment for potential confounders, every 1 mg of intravenous morphine equivalent dose was associated with a 1.4% (95% CI 0.2%, 2.7%, p=0.028) increase in peak creatine kinase; however, this was no longer significant after adjustment for TIMI flow pre-PCI. CONCLUSIONS Our study suggests no benefit of higher opioid dose and a dose-dependent signal between opioid dose and increased myocardial infarct size. Prospective randomised controlled trials are required to establish causality given that this may also be explained by patients with a greater ischaemic burden requiring higher opioid doses due to more severe pain. Future research also needs to focus on strategies to mitigate the opioid-P2Y12 inhibitor interaction and non-opioid analgesia to treat ischaemic chest pain.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Atherothrombosis and Vascular Biology, Baker Heart Research Institute, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Atherothrombosis and Vascular Biology, Baker Heart Research Institute, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Janet Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andris Ellims
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Andrew Taylor
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Centre, Baker Heart Research Institute, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Heart Centre, Baker Heart Research Institute, Melbourne, Victoria, Australia
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Charpentier S, Galinski M, Bounes V, Ricard-Hibon A, El-Khoury C, Elbaz M, Ageron FX, Manzo-Silberman S, Soulat L, Lapostolle F, Gérard A, Bregeaud D, Bongard V, Bonnefoy-Cudraz E. Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study. Scand J Trauma Resusc Emerg Med 2020; 28:36. [PMID: 32398160 PMCID: PMC7218609 DOI: 10.1186/s13049-020-00731-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
Background Studies have shown disparate results on the consequences of morphine use in ST-segment elevation myocardial infarction (STEMI). No study has evaluated alternative treatments that could be at least non-inferior to morphine without its potentially damaging consequences for myocardial function and platelet reactivity. The aim of this study was to evaluate whether nitrous oxide/oxygen plus intravenous acetaminophen (NOO-A) is non-inferior to morphine to control chest pain in STEMI patients. Methods This multicenter, open-label, cluster-randomized, controlled, non-inferiority study compared NOO-A with morphine in 684 prehospital patients with ongoing suspected STEMI of < 12 h duration and a pain rating score ≥ 4. The primary endpoint was the proportion of patients achieving pain relief (numeric rating score ≤ 3) after 30 min. Secondary safety endpoints included serious adverse events and death at 30 days. Results The median baseline pain score was 7.0 in both groups. The primary endpoint occurred in 51.7% of the NOO-A group and 73.6% of the morphine group (absolute risk difference − 21.7%; 95% confidence interval − 29.6 to − 13.8). At 30 days, the rate of serious adverse events was 16.0 and 18.8% in the NOO-A and morphine groups respectively (p = NS). The rate of death was 1.8% (NOO-A group) and 3.8% (morphine group) (p = NS). Conclusion Analgesia provided by NOO-A was inferior to morphine at 30 min in patients with acute STEMI in the prehospital setting. Rates of serious adverse events did not differ between groups. Trial registration ClinicalTrials.gov: NCT02198378.
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Affiliation(s)
- Sandrine Charpentier
- Emergency Department, Toulouse University Hospital, INSERM UMR 1027, University Toulouse III Paul Sabatier, Toulouse, France. .,Emergency Department, Rangueil University Hospital, 1 Av. Jean Poulhès, 31059, Toulouse, France.
| | - Michel Galinski
- Emergency Department - SAMU 33, CHU de Bordeaux; INSERM U1219 - Injury Epidemiology Transport Occupation" team, University Bordeaux II, 33000, Bordeaux, France
| | - Vincent Bounes
- SAMU31, Toulouse University Hospital; University Toulouse III Paul Sabatier, Toulouse, France
| | - Agnès Ricard-Hibon
- Pôle Emergency Department, SAMU - Centre Hospitalier René Dubos Pontoise, 95300, Pontoise, France
| | - Carlos El-Khoury
- Emergency Department and RESCUe Network, Lucien Hussel Hospital, Vienne, France.,Univ. Lyon, Claude Bernard Lyon 1 University, HESPER EA, 7425, Lyon, France
| | - Meyer Elbaz
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | | | - Stéphane Manzo-Silberman
- Cardiology department, Lariboisire Hospital, APHP, Paris, France.,Paris VII University UMRS 942, Paris, France
| | - Louis Soulat
- SAMU 35 SMUR Urgences adultes, Centre Hospitalier Universitaire Rennes, Université Rennes 1, Rennes, France
| | - Frédéric Lapostolle
- SAMU 93 - UF Recherche-Enseignement-Qualité Université Paris 13, Sorbonne Paris Cité, Inserm U942 Hôpital Avicenne, AP-HP, 125, rue de Stalingrad, 93009, Bobigny, France
| | - Alexandre Gérard
- Hospices Civils de Lyon SAMU 69 - Hôpital Édouard HERRIOT 5, place d'Arsonval, 69437, LYON Cedex 03, France
| | | | - Vanina Bongard
- Department of Epidemiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Department of Public Health, Université Toulouse 3; UMR 1027 INSERM - Université Toulouse 3, Toulouse, France
| | - Eric Bonnefoy-Cudraz
- Hôpital cardiologique Louis-Pradel, 69500, Lyon, France.,Université Lyon-1, 69100, Lyon, France
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Abstract
Analgesics, particularly opioids, have been routinely used in the emergency treatment of ischemic chest pain for a long time. In the past two decades; however, several studies have raised the possibility of the harmful effects of opioid administration. In 2014, the American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) changed the guidelines regarding the use of opioids from class IC to class IIb for non-ST elevation acute coronary syndrome. And in 2015, the European Society of Cardiology (ESC) guidelines incidentally noted the side effects of opioids. In ST-segment elevation myocardial infarction, both ESC and AHA/ACCF still recommend the use of opioids. Given the need for adequate pain relief in ischemic chest pain in the emergency setting, it is necessary to understand the adverse effects of analgesia, while still providing sufficiently potent options for analgesia. The primary purpose of this review is to quantify the effects of analgesics commonly used in the prehospital and emergency department in patients with ischemic chest pain.
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Impact of Morphine Treatment on Infarct Size and Reperfusion Injury in Acute Reperfused ST-Elevation Myocardial Infarction. J Clin Med 2020; 9:jcm9030735. [PMID: 32182847 PMCID: PMC7141264 DOI: 10.3390/jcm9030735] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/19/2020] [Accepted: 02/27/2020] [Indexed: 12/20/2022] Open
Abstract
Current evidence regarding the effect of intravenous morphine administration on reperfusion injury and/or cardioprotection in patients with myocardial infarction is conflicting. The aim of this study was to evaluate the impact of morphine administration, on infarct size and reperfusion injury assessed by cardiac magnetic resonance imaging (CMR) in a large multicenter ST-elevation myocardial infarction (STEMI) population. In total, 734 STEMI patients reperfused by primary percutaneous coronary intervention <12 h after symptom onset underwent CMR imaging at eight centers for assessment of myocardial damage. Intravenous morphine administration was recorded in all patients. CMR was completed within one week after infarction using a standardized protocol. The clinical endpoint of the study was the occurrence of major adverse cardiac events (MACE) within 12 months after infarction. Intravenous morphine was administered in 61.8% (n = 454) of all patients. There were no differences in infarct size (17%LV, interquartile range [IQR] 8–25%LV versus 16%LV, IQR 8–26%LV, p = 0.67) and microvascular obstruction (p = 0.92) in patients with versus without morphine administration. In the subgroup of patients with early reperfusion within 120 min and reduced flow of the infarcted vessel (TIMI-flow ≤2 before PCI) morphine administration resulted in significantly smaller infarcts (12%LV, IQR 12–19 versus 19%LV, IQR 10–29, p = 0.035) and reduced microvascular obstruction (p = 0.003). Morphine administration had no effect on hard clinical endpoints (log-rank test p = 0.74) and was not an independent predictor of clinical outcome in Cox regression analysis. In our large multicenter CMR study, morphine administration did not have a negative effect on myocardial damage or clinical prognosis in acute reperfused STEMI. In patients, presenting early ( ≤120 min) morphine may have a cardioprotective effect as reflected by smaller infarcts; but this finding has to be assessed in further well-designed clinical studies
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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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