1
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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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2
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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: 5] [Impact Index Per Article: 5.0] [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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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
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4
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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: 12] [Impact Index Per Article: 4.0] [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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5
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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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7
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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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8
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Marin W, Marin D, Ao X, Liu Y. Mitochondria as a therapeutic target for cardiac ischemia‑reperfusion injury (Review). Int J Mol Med 2020; 47:485-499. [PMID: 33416090 PMCID: PMC7797474 DOI: 10.3892/ijmm.2020.4823] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/18/2020] [Indexed: 02/07/2023] Open
Abstract
Acute myocardial infarction is the leading cause of cardiovascular-related mortality and chronic heart failure worldwide. As regards treatment, the reperfusion of ischemic tissue generates irreversible damage to the myocardium, which is termed 'cardiac ischemia-reperfusion (IR) injury'. Due to the large number of mitochondria in cardiomyocytes, an increasing number of studies have focused on the roles of mitochondria in IR injury. The primary causes of IR injury are reduced oxidative phosphorylation during hypoxia and the increased production of reactive oxygen species (ROS), together with the insufficient elimination of these oxidative species following reperfusion. IR injury includes the oxidation of DNA, incorrect modifications of proteins, the disruption of the mitochondrial membrane and respiratory chain, the loss of mitochondrial membrane potential (∆Ψm), Ca2+ over-load, mitochondrial permeability transition pore formation, swelling of the mitochondria, and ultimately, cardiomyocyte necrosis. The present review article discusses the molecular mechanisms of IR injury, and summarizes the metabolic and dynamic changes occurring in the mitochondria in response to IR stress. The mitochondria are strongly recommended as a target for the development of therapeutic agents; however, the appropriate use of agents remains a challenge.
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Affiliation(s)
- Wenwen Marin
- Institute for Translational Medicine, The Affiliated Hospital of Qingdao University, College of Medicine, Qingdao University, Qingdao, Shandong 266071, P.R. China
| | - Dennis Marin
- Qingdao University of Science and Technology, Qingdao, Shandong 266061, P.R. China
| | - Xiang Ao
- School of Basic Medical Sciences, College of Medicine, Qingdao University, Qingdao, Shandong 266071, P.R. China
| | - Ying Liu
- Institute for Translational Medicine, The Affiliated Hospital of Qingdao University, College of Medicine, Qingdao University, Qingdao, Shandong 266071, P.R. China
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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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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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Jones MR, Kramer ME, Beutler SS, Kaye AD, Rao N, Brovman EY, Urman RD. The Association Between Potential Opioid-Related Adverse Drug Events and Outcomes in Total Knee Arthroplasty: A Retrospective Study. Adv Ther 2020; 37:200-212. [PMID: 31664696 DOI: 10.1007/s12325-019-01122-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Characterization of the clinical and economic impact of opioid-related adverse drug events (ORADEs) after total knee arthroplasty (TKA) may guide provider and hospital system approach to managing postoperative pain after TKA. Our analysis quantifies the rate of potential ORADEs after TKA, the impact of potential ORADEs on length of stay (LOS) and hospital revenue, as well as their association with specific patient risk factors and comorbid clinical conditions. METHODS We conducted a retrospective study using the Centers for Medicare and Medicaid Services administrative database to analyze Medicare discharges involving two knee replacement surgery diagnosis-related groups (DRGs) in order to identify potential ORADEs. The impact of potential ORADEs on mean hospital LOS and hospital revenue was analyzed. RESULTS The potential ORADE rate in patients who underwent TKA was 25,523 out of 316,858 records analyzed (8.0%). The mean LOS for patients who experienced a potential ORADE was 1.04 days longer than those without an ORADE. The mean hospital revenue per day with a potential ORADE was $1334 (USD) less than without an ORADE. Potential ORADEs were significantly associated with poor patient outcomes such as pneumonia, septicemia, and shock. CONCLUSION Potential ORADEs in TKA are associated with longer hospitalizations, decreased hospital revenue, and poor patient outcomes. Certain risk factors may predispose patients to experiencing an ORADE, and thus perioperative pain management strategies that reduce the frequency of ORADEs particularly in at-risk patients can improve patient satisfaction and increase hospital revenue following TKAs.
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Affiliation(s)
- Mark R Jones
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, FD-221A, Boston, MA, 02215, USA
| | - MaryJo E Kramer
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Alan D Kaye
- Department of Anesthesiology, 1542 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Nikhilesh Rao
- Dexur Research and Analytics, 311 W 43rd St, New York, NY, 10036, USA
| | - Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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