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Ye R, Jneid H, Alam M, Uretsky BF, Atar D, Kitakaze M, Davidson SM, Yellon DM, Birnbaum Y. Do We Really Need Aspirin Loading for STEMI? Cardiovasc Drugs Ther 2022; 36:1221-1238. [PMID: 35171384 DOI: 10.1007/s10557-022-07327-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2022] [Indexed: 12/12/2022]
Abstract
Aspirin loading (chewable or intravenous) as soon as possible after presentation is a class I recommendation by current ST elevation myocardial infarction (STEMI) guidelines. Earlier achievement of therapeutic antiplatelet effects by aspirin loading has long been considered the standard of care. However, the effects of the loading dose of aspirin (alone or in addition to a chronic maintenance oral dose) have not been studied. A large proportion of myocardial cell death occurs upon and after reperfusion (reperfusion injury). Numerous agents and interventions have been shown to limit infarct size in animal models when administered before or immediately after reperfusion. However, these interventions have predominantly failed to show significant protection in clinical studies. In the current review, we raise the hypothesis that aspirin loading may be the culprit. Data obtained from animal models consistently show that statins, ticagrelor, opiates, and ischemic postconditioning limit myocardial infarct size. In most of these studies, aspirin was not administered. However, when aspirin was administered before reperfusion (as is the case in the majority of studies enrolling STEMI patients), the protective effects of statin, ticagrelor, morphine, and ischemic postconditioning were attenuated, which can be plausibly attributable to aspirin loading. We therefore suggest studying the effects of aspirin loading before reperfusion on the infarct size limiting effects of statins, ticagrelor, morphine, and/ or postconditioning in large animal models using long reperfusion periods (at least 24 h). If indeed aspirin attenuates the protective effects, clinical trials should be conducted comparing aspirin loading to alternative antiplatelet regimens without aspirin loading in patients with STEMI undergoing primary percutaneous coronary intervention.
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Affiliation(s)
- Regina Ye
- University of Texas at Austin, Austin, TX, USA
| | - Hani Jneid
- Department of Medicine Baylor College of Medicine, 7200 Cambridge Street Houston, Texas, 77030, USA
| | - Mahboob Alam
- Department of Medicine Baylor College of Medicine, 7200 Cambridge Street Houston, Texas, 77030, USA
| | - Barry F Uretsky
- University of Arkansas for Medical Sciences, Central Arkansas Veterans Health System, Little Rock, AR, USA
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Masafumi Kitakaze
- Center of Medical Innovation and Translational Research, Department of Medical Data Science, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Yochai Birnbaum
- Department of Medicine Baylor College of Medicine, 7200 Cambridge Street Houston, Texas, 77030, USA.
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Koh JQS, Fernando H, Peter K, Stub D. Opioids and ST Elevation Myocardial Infarction: A Systematic Review. Heart Lung Circ 2019; 28:697-706. [DOI: 10.1016/j.hlc.2018.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/18/2018] [Accepted: 12/20/2018] [Indexed: 11/26/2022]
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Aeyels D, Sinnaeve PR, Claeys MJ, Gevaert S, Schoors D, Sermeus W, Panella M, Coeckelberghs E, Bruyneel L, Vanhaecht K. Key interventions and quality indicators for quality improvement of STEMI care: a RAND Delphi survey. Acta Cardiol 2017; 73:1-10. [PMID: 29237337 DOI: 10.1080/00015385.2017.1411664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/25/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Identification, selection and validation of key interventions and quality indicators for improvement of in hospital quality of care for ST-elevated myocardial infarction (STEMI) patients. METHODS AND RESULTS A structured literature review was followed by a RAND Delphi Survey. A purposively selected multidisciplinary expert panel of cardiologists, nurse managers and quality managers selected and validated key interventions and quality indicators prior for quality improvement for STEMI. First, 34 experts (76% response rate) individually assessed the appropriateness of items to quality improvement on a nine point Likert scale. Twenty-seven key interventions, 16 quality indicators at patient level and 27 quality indicators at STEMI care programme level were selected. Eighteen additional items were suggested. Experts received personal feedback, benchmarking their score with group results (response rate, mean, median and content validity index). Consequently, 32 experts (71% response rate) openly discussed items with an item-content validity index above 75%. By consensus, the expert panel validated a final set of 25 key interventions, 13 quality indicators at patient level and 20 quality indicators at care programme level prior for improvement of in hospital care for STEMI. CONCLUSIONS A structured literature review and multidisciplinary expertise was combined to validate a set of key interventions and quality indicators prior for improvement of care for STEMI. The results allow researchers and hospital staff to evaluate and support quality improvement interventions in a large cohort within the context of a health care system.
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Affiliation(s)
- Daan Aeyels
- a Leuven Institute for Healthcare Policy , Katholieke Universiteit Leuven , Leuven , Belgium
| | - Peter R Sinnaeve
- b Department of Cardiology , University Hospitals Leuven , Leuven , Belgium
| | - Marc J Claeys
- c Department of Cardiology , Antwerp University Hospital , Edegem , Belgium
| | - Sofie Gevaert
- d Department of Cardiology , Ghent University Hospital , Ghent , Belgium
| | - Danny Schoors
- e Department of Cardiology , University Hospitals Brussels , Brussels , Belgium
| | - Walter Sermeus
- f Institute for Healthcare Policy , University of Leuven , Leuven , Belgium
| | - Massimiliano Panella
- g Department of Clinical and Experimental Medicine , Amedeo Avogadro University of Eastern Piedmont , Vercelli , Italy
| | | | - Luk Bruyneel
- f Institute for Healthcare Policy , University of Leuven , Leuven , Belgium
| | - Kris Vanhaecht
- h Department of Quality Management , University Hospitals Leuven , Leuven , Belgium
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Pan Z, Qi Y, Wen Y, Chen L. Intravenous morphine titration as a rapid and efficient analgesia for adult patients with femoral shaft fractures after injury. Am J Emerg Med 2016; 34:2107-2111. [PMID: 27524680 DOI: 10.1016/j.ajem.2016.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/15/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022] Open
Abstract
This study aimed to compare the analgesic effects of intravenous ibuprofen and intravenous morphine titration for femoral shaft fractures in adult patients. In total, 293 participants were enrolled and randomly received intravenous ibuprofen or intravenous morphine titration. Their visual analogue scale (VAS) results were recorded every 5 minutes after the first administration. The VAS scores before and during transport were also measured. Meanwhile, the type and frequency of the adverse effects were also recorded in both groups. Patients treated with morphine showed a faster and greater reduction in the VAS than those in the ibuprofen group within 1 hour after the first administration. Interestingly, intravenous morphine titration provided consistent analgesia even during the further transport. No significant immediate adverse event was observed in all of the participants, except for sedation, which might be beneficial for keeping the patient quiet and might not be arbitrarily attributed to adverse effects. No addiction was noted in the morphine group. This study demonstrated that intravenous morphine titration is a faster and more efficient analgesia for femoral shaft fractures than ibuprofen in adult patients immediately after injury.
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Affiliation(s)
- Zhengqi Pan
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Yongjian Qi
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Yinxian Wen
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Liaobin Chen
- Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
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