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Prehospital opioid dose and myocardial injury in patients with ST elevation myocardial infarction

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journal contribution
posted on 29.01.2021, 03:20 by Himawan Fernando, Ziad Nehme, Karlheinz PeterKarlheinz Peter, Stephen Bernard, Michael Stephenson, Janet Bray, Peter Cameron, Andris Ellims, Andrew Taylor, David M Kaye, Karen Smith, Dion Stub
ObjectiveTo characterise the relationship between opioid dose and myocardial infarct size in patients with ST elevation myocardial infarction (STEMI).MethodsPatients given opioid treatment by emergency medical services with confirmed STEMI were included in this secondary, retrospective cohort analysis of the Air versus Oxygen in Myocardial Infarction (AVOID) study. Patients with cardiogenic shock were excluded. The primary endpoint was comparison of cardiac biomarkers as a measure of infarct size based on opioid dose (low ≤8.75 mg, intermediate 8.76–15 mg and high >15 mg of intravenous morphine equivalent dose).Results422 patients were included in the analysis. There was a significantly higher proportion of patients with Thrombolysis in Myocardial Infarction (TIMI) 0 or 1 flow pre-percutaneous coronary intervention (PCI) (94% vs 81%, p=0.005) and greater use of thrombus aspiration catheters (59% vs 30%, p<0.001) in the high compared with low-dose opioid group. After adjustment for potential confounders, every 1 mg of intravenous morphine equivalent dose was associated with a 1.4% (95% CI 0.2%, 2.7%, p=0.028) increase in peak creatine kinase; however, this was no longer significant after adjustment for TIMI flow pre-PCI.ConclusionsOur study suggests no benefit of higher opioid dose and a dose-dependent signal between opioid dose and increased myocardial infarct size. Prospective randomised controlled trials are required to establish causality given that this may also be explained by patients with a greater ischaemic burden requiring higher opioid doses due to more severe pain. Future research also needs to focus on strategies to mitigate the opioid–P2Y12 inhibitor interaction and non-opioid analgesia to treat ischaemic chest pain.

Funding

The AVOID study was funded by grants from Alfred Foundation, FALCK foundation and Paramedics Australia.

History

Publication Date

22/07/2020

Journal

OPEN HEART

Volume

7

Issue

2

Article Number

e001307

Pagination

7p. (p. 1-7)

Publisher

BMJ PUBLISHING GROUP

ISSN

2053-3624

Rights Statement

The Author reserves all moral rights over the deposited text and must be credited if any re-use occurs. Documents deposited in OPAL are the Open Access versions of outputs published elsewhere. Changes resulting from the publishing process may therefore not be reflected in this document. The final published version may be obtained via the publisher’s DOI. Please note that additional copyright and access restrictions may apply to the published version.