Morphine in the Setting of Acute Heart Failure: Do the Risks Outweigh the Benefits?

Clinical outcomes of opioid administration in acute and chronic heart failure: A meta-analysis

BACKGROUND AND AIMS

Opioid use in heart failure (HF) management is controversial, and whether rapid symptomatic relief outweighs the risks of opioid use in HF remains unknown. This study aimed to explore the clinical outcomes of opioid administration in patients with acute or chronic HF.

METHODS

A systematic search for eligible studies was conducted in databases (MEDLINE, Scopus, Web of Science, EBSCO) and registries (ClinicalTrials.gov, WHO Clinical Trial Registry) until June 8, 2022. Odds ratios (ORs) or adjusted OR (aORs) and mean difference (MD) or standardized MD were quantified for binary and continuous outcomes, respectively. Meta-regression was performed using the restricted maximum likelihood method.

RESULTS

A total of 20 studies (154,736 participants) were included. In acute HF, opioid use presented a high risk for in-hospital mortality (OR = 2.35; 95% confidence interval (CI): 1.03-5.38; I² = 97%), invasive (OR = 2.78; 95%CI: 1.17-6.61; I² = 93%) and noninvasive (OR = 2.97; 95%CI: 1.06-8.28; I² = 95%) ventilations, intensive care unit admission (OR = 3.62; 95%CI: 3.11-4.21; I² = 6%), and inotrope use (OR = 2.54; 95%CI: 1.94-3.32; I² = 63%). In chronic HF New York Heart Association (NYHA) Class II/III, opioid use improved ventilatory efficiency (MD = -3.16; 95%CI: (-4.78)-(-1.54); I² = 0%), and exercise test duration (MD = 69.24; 95%CI: 10.11-128.37; I² = 89%).

CONCLUSIONS

Opioids are not recommended for acute HF management; however, they showed an advantage in exercise testing by improving ventilatory efficiency, chemosensitivity, and exercise test duration in stable patients with chronic HF NYHA Class II/III. Nonetheless, larger randomized controlled trials and individual patient-level data meta-analyses are warranted.

The safety of morphine in patients with acute heart failure: A systematic review and meta-analysis

While morphine has long been widely used in treating acute heart failure (AHF) due to its vasodilatory properties and anticipated anxiolysis, it remains unclear whether the application of morphine to those patients is reasonable. We aim to conduct a systematic review and meta-analysis to assess the safety of morphine in patients with AHF. We searched PubMed, Cochrane Library, and Embase electronic databases from inception through March 2020. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were used to estimate the outcomes. Seven studies with 172, 226 patients were included. The results showed that morphine usage was not associated with increased in-hospital mortality (OR: 1.94; 95% CI 0.93 to 4.03; p = 0.08). However, the use of morphine significantly increased the risk of invasive ventilation (OR: 2.72; 95% CI 1.09 to 6.80; p = 0.03). Furthermore, the subgroup analysis indicated that the application of morphine was not associated with increased 7-day all-cause mortality in patients with AHF (OR: 1.69; 95% CI 0.80 to 3.22; p = 0.11) but significantly increased the risk of 30-day all-cause mortality (OR: 1.59; 95% CI 1.16 to 2.17; p = 0.004). Based on current evidence, our results suggested that although morphine therapy did not significantly increase the risk of short-term death (in the hospital or within 7 days) in patients with AHF, the risk of long-term death and invasive ventilation were significantly increased. This result needs to be further confirmed by an ongoing randomized control trial.