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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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Vilcane S, Scharonow O, Weilbach C, Scharonow M. Application of analgesics in emergency services in Germany: a survey of the medical directors. BMC Emerg Med 2023; 23:104. [PMID: 37710177 PMCID: PMC10500886 DOI: 10.1186/s12873-023-00878-8] [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: 06/03/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
ABSTRAC BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for improvement in the prehospital analgesia. OBJECTIVE The aim of this study is to assess the current situation in out of hospital pain management in Germany regarding the substances, indications, dosage and the delegation of the use of analgesics to emergency medical service (EMS) staff. MATERIAL AND METHODS A standardized survey of the medical directors of the emergency services (MDES) in Germany was carried out using an online questionnaire. The anonymous results were evaluated using the statistical software SPSS (Chi-squared test, Mann-Whitney-U test). RESULTS Seventy-seven MDES responsible for 989 rescue stations and 397 EMS- physician bases in 15 federal states took part in this survey. Morphine (98.7%), Fentanyl (85.7%), Piritramide (61%), Sufentanil (18.2%) and Nalbuphine (14,3%) are provided as opioid analgesics. The non-opioid analgesics (NOA) including Ketamine/Esketamine (98,7%), Metamizole (88.3%), Paracetamol (66,2%), Ibuprofen (24,7%) and COX-2-inhibitors (7,8%) are most commonly available. The antispasmodic Butylscopolamine is available (81,8%) to most rescue stations. Fentanyl is the most commonly provided opioid analgesic for treatment of a traumatic pain (70.1%) and back pain (46.8%), Morphine for visceral colic-like (33.8%) and non-colic pain (53.2%). In cases of acute coronary syndrome is Morphine (85.7%) the leading analgesic substance. Among the non-opioid analgesics is Ketamine/Esketamine (90.9%) most frequently provided to treat traumatic pain, Metamizole for visceral colic-like (70.1%) and non-colic (68.6%) as well as back pain (41.6%). Butylscopolamine is the second most frequently provided medication after Metamizole for "visceral colic-like pain" (55.8%). EMS staff (with or without a request for presence of the EMS physician on site) are permitted to use the following: Morphine (16.9%), Piritramide (13.0%) and Nalbuphine (10.4%), and of NOAs for (Es)Ketamine (74.1%), Paracetamol (53.3%) and Metamizole (35.1%). The dosages of the most important and commonly provided analgesic substances permitted to independent treatment by the paramedics are often below the recommended range for adults (RDE). The majority of medical directors (78.4%) of the emergency services consider the independent application of analgesics by paramedics sensible. The reason for the relatively rare authorization of opioids for use by paramedics is mainly due to legal (in)certainty (53.2%). CONCLUSION Effective analgesics are available for EMS staff in Germany, the approach to improvement lies in the area of application. For this purpose, the adaptations of the legal framework as well as the creation of a guideline for prehospital analgesia are useful.
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Affiliation(s)
- Signe Vilcane
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
| | - Olga Scharonow
- Department of Internal Medicine, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Cloppenburg, Germany
| | - Christian Weilbach
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
| | - Maximilian Scharonow
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
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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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Buckley JP, Mylotte D, McEvoy JW. Platelets and poppies: Do morphine and fentanyl differ? Int J Cardiol 2021; 333:43-44. [PMID: 33753184 DOI: 10.1016/j.ijcard.2021.03.037] [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: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 11/29/2022]
Affiliation(s)
- John P Buckley
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Darren Mylotte
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - John W McEvoy
- School of Medicine, National University of Ireland Galway, Galway, Ireland; National Institute for Prevention and Cardiovascular Health, School of Medicine, National University of Ireland Galway, Galway, Ireland.
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