Effects of lignocaine vs. opioids on antiplatelet activity of ticagrelor: the LOCAL trial

Beyond Traditional Pain Relief: A Review of Alternative Analgesics in Myocardial Infarction Patient Management

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.

Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease

Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.

Parenteral Antiplatelet Drugs in ST-Elevation Myocardial Infarction: Current Status and Future Directions

Oral inhibitors of the platelet P2Y₁₂ receptor are indispensable in the treatment of ST-elevation myocardial infarction (STEMI), improving outcomes and even reducing mortality in some studies. However, these drugs are limited by delayed absorption and suboptimal platelet inhibition at the time of primary percutaneous coronary intervention. Despite efforts to achieve faster and more sustained platelet inhibition, strategies such as prehospital administration, higher loading doses, and crushed formulations have not led to improved coronary reperfusion. Parenteral glycoprotein IIb/IIIa inhibitors act sooner and are more potent than oral P2Y₁₂ inhibitors, but their use has been limited by the increased risk of major bleeding and thrombocytopenia. Hence, there is a clinical need to refine drugs that deliver rapid, effective, yet safe platelet inhibition in the setting of STEMI. Novel parenteral antiplatelet drugs, such as cangrelor, selatogrel, and zalunfiban, have been recently developed to achieve rapid, potent antiplatelet effects while preserving hemostasis. We provide a description of currently available parenteral antiplatelet agents and of those in clinical development for prehospital administration in STEMI patients.

LidocAine Versus Opioids In MyocarDial infarction: the AVOID-2 randomized controlled trial

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.

Analgesic drug use in patients with STEMI: Current perspectives and challenges

Therapy for patients with ST-elevation myocardial infarction (STEMI) has been a controversial topic since the introduction of thrombolytic agents in the 1980s. The use of morphine, fentanyl and lidocaine has increased substantially during this period. However, there is still limited evidence on their advantages and limitations. In this review, the clinical application, as well as future considerations of morphine, fentanyl and lidocaine in patients with ST segment elevation myocardial infarction were discussed.

Morphine and clinical outcomes in patients with ST segment elevation myocardial infarction treated with fibrinolytic and antiplatelet therapy: Insights from the TREAT trial

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.

P2Y12 Antagonists in Cardiovascular Disease—Finding the Best Balance Between Preventing Ischemic Events and Causing Bleeding

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.

Association between pre-hospital chest pain severity and myocardial injury in ST elevation myocardial infarction: A post-hoc analysis of the AVOID study

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.

P2Y12 inhibition in acute coronary syndromes treated with percutaneous intervention - Understanding the debate on Prasugrel or Ticagrelor

After more than 10 years of routine clinical use, a debate about the preference of prasugrel over ticagrelor has been unveiled following publication of the ISAR-REACT 5 trial, an investigator-initiated trial directly comparing both substances as part of dual anti-platelet therapy following interventional treatment in patients with acute coronary syndromes (ACS). Both substances had been tested in trials, approved by authorities and subsequently recommended by guidelines according to the strategy applied in the respective approval trial. This resulted in prasugrel tested in TRITON only be given after diagnostic coronary angiography in the absence of ST-segment elevations (NSTE-ACS) and ticagrelor tested in PLATO being administered even before diagnostic coronary angiography in all forms of acute coronary syndromes. Whichever way was safest and most efficient, had never been clarified before. ISAR-REACT 5 showed superior efficacy of prasugrel over ticagrelor in general, and of deferred administration of prasugrel over pre-treatment with ticagrelor in NSTE-ACS patients undergoing percutaneous coronary interventions. Subsequently, in 2020 the European guidelines for NSTE-ACS adopted both positions in recommending the respective preference. Afterwards, a confrontational debate erupted between those favouring the ISAR-REACT 5 results and their implementation in guidelines and others still preferring the generalized interpretation of the overall study results from PLATO. In this review, we reflect the history leading to trial design of TRITON and PLATO and the way this subsequently impacted on clinical practice and guideline recommendations.