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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Chen H, Wang H, Li B, Hong L, Kuang M, Yang L. Analgesic drug use in patients with STEMI: Current perspectives and challenges. Front Med (Lausanne) 2023; 10:1148581. [PMID: 37035322 PMCID: PMC10073464 DOI: 10.3389/fmed.2023.1148581] [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: 01/20/2023] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
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.
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Affiliation(s)
- Huaigang Chen
- Medical College of Nanchang University, Nanchang, Jiangxi Province, China
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Hong Wang
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Bin Li
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Lang Hong
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Maobin Kuang
- Medical College of Nanchang University, Nanchang, Jiangxi Province, China
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
| | - Liu Yang
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
- *Correspondence: Liu Yang,
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3
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Basalay MV, Yellon DM, Davidson SM. Opioids in Acute Coronary Syndromes: Friend or Foe? Cardiovasc Drugs Ther 2022; 36:1001-1003. [PMID: 35793001 DOI: 10.1007/s10557-022-07364-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Maryna V Basalay
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK.
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4
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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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5
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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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6
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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7
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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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8
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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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9
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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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10
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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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Kubica A, Kosobucka A, Niezgoda P, Adamski P, Buszko K, Lesiak M, Wojakowski W, Gasior M, Gorący J, Kleinrok A, Nadolny K, Navarese E, Kubica J. ANalgesic Efficacy and safety of MOrphiNe versus methoxyflurane in patients with acute myocardial infarction: the rationale and design of the ANEMON-SIRIO 3 study: a multicentre, open-label, phase II, randomised clinical trial. BMJ Open 2021; 11:e043330. [PMID: 33649058 PMCID: PMC8098993 DOI: 10.1136/bmjopen-2020-043330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION The unfavourable influence of morphine on the pharmacokinetics of ticagrelor resulting in weaker and retarded antiplatelet effect in patients with acute coronary syndrome (ACS) has been previously shown. Replacing morphine with methoxyflurane, a potent, non-opioid analgesic agent, that does not weaken or delay the effect of antiplatelet agents may improve the clinical efficacy of treatment of patients with ACS. METHODS The ANEMON-SIRIO 3 study was designed as a multicentre, open-label, phase II, randomised clinical trial aimed to test the analgesic efficacy and safety of methoxyflurane in patients with ACS. The study population will comprise patients with ST-elevation myocardial infarction or non-ST-elevation ACS admitted to the study centres with typical chest pain requiring analgesic treatment. Before percutaneous coronary intervention (PCI) for the patients with index ACS will be randomly assigned in 1:1 ratio to receive methoxyflurane administered by inhalation, or to obtain morphine administered intravenously. Analgesic treatment will be followed by 300 mg loading dose of aspirin and 180 mg loading dose of ticagrelor. Patients will be assessed with regard to pain intensity according to the Numeric Pain Rating Scale at baseline, 3 min after study drug administration and immediately after PCI. Moreover, patients will be actively monitored with regard to the occurrence of side effects of evaluated therapies, as well as adverse events that may be related to insufficient platelet inhibition (no-reflow phenomenon assessed immediately after PCI, administration of GPIIb/IIIa inhibitors during PCI, acute stent thrombosis). ETHICS AND DISSEMINATION The study will be conducted in six Polish clinical centres from the beginning of in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. TRIAL REGISTRATION DETAILS ClinicalTrials.gov, NCT04476173.
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Affiliation(s)
- Aldona Kubica
- Departament of Health Promotion, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Agata Kosobucka
- Departament of Health Promotion, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Piotr Niezgoda
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Katarzyna Buszko
- Department of Theoretical Foundations of Biomedical Science and Medical Informatics, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Maciej Lesiak
- The 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Mariusz Gasior
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry, Medical University of Silesia, Zabrze, Poland
| | - Jarosław Gorący
- Department of Cardiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Andrzej Kleinrok
- Department of Cardiology, Pope John Paul II Reginal Hospital, Zamosc, Poland
- Medical Department, University of Information Technology and Management, Rzeszow, Poland
| | - Klaudiusz Nadolny
- Department of Emergency Medicine and Disasters, Medical University of Bialystok, Bialystok, Poland
- Department of Emergency Medical Service, Higher School of Strategic Planning, Dąbrowa Górnicza, Poland
| | - Eliano Navarese
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
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