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Morphine for chest pain (angina) increases death
risk
6/11/04 - 10/11/04, New Orleans, LA
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Scientific Sessions, the largest cardiovascular meeting
in the world, is being held in New Orleans Nov. 6–10.
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DURHAM, N.C. -- While patients hospitalized for a heart
attack have long been treated with morphine to relieve chest
pain, a new analysis by researchers from the Duke Clinical
Research Institute has shown that these patients have almost a
50 percent higher risk of dying.
The researchers call for a randomized clinical trial to
confirm their analysis. Meanwhile, they advise cardiologists to
begin treatment with sufficient doses of nitroglycerin to relive
pain before resorting to morphine.
In their analysis of the clinical data and outcomes of more
than 57,000 high-risk heart attack patients -- 29.8 percent of
whom received morphine within the first 24 hours of
hospitalization -- the researchers found that those who received
morphine had a 6.8 percent death rate, compared to 3.8 percent
for those receiving nitroglycerin. The increase in mortality
persisted even after adjustment for the patients' baseline
clinical risk.
"The results of this analysis raise serious concerns about
the safety of the routine use of morphine in this group of heart
patients," said Duke cardiologist Trip Meine, M.D., who
presented the results of the Duke analysis Nov. 10, 2004, at the
American Heart Association's (AHA) annual scientific sessions in
New Orleans.
"Since randomized clinical trials evaluating the safety or
effectiveness of morphine for these patients have not been
conducted, official guidelines for its use are based solely on
expert conjecture," Meine continued. "Given the adverse outcomes
associated with morphine use found in our analysis, a randomized
clinical trial is in order."
Morphine was first used to relieve the chest pain associated
with heart attacks in 1912 and has been used regularly ever
since. Nitroglycerin has been used for more than 130 years for
the relief of chest pain, also known as unstable angina. It
works by relaxing blood vessels and allowing blood flow to
increase.
"Nitroglycerin has a physiological effect that may, at least
temporarily, influence the underlying ischemia," Meine said.
"Morphine, on the other hand, doesn't do anything about what is
actually causing the pain. It just masks it, and may, in fact,
make the underlying disease worse.
"Morphine has the well-known and potentially harmful side
effects of depressing respiration, reducing blood pressure and
slowing heart rate," he continued. "These side effects could
explain the worse outcomes in patients whose heart function has
already been compromised by disease."
For their analysis, the researchers consulted the nationwide
quality improvement initiative named CRUSADE (Can Rapid Risk
Stratification of Unstable Angina Patients Suppress Adverse
Outcomes with Early Implementation of the American College of
Cardiology and AHA Guidelines) The registry continually collects
data from more than 400 hospitals on outcomes and on the use of
proven drugs and procedures used to restore blood flow to the
heart.
From this registry, the researchers identified 57,039
high-risk patients with non-ST-segment elevation myocardial
infarction (non-STEMI), a categorization of heart attack based
on electrocardiogram (ECG) readings. These patients typically
arrive at emergency rooms with chest pain, but often will not
have telltale signs of a heart attack on the initial ECG. They
might be diagnosed with a heart attack only when the results of
the blood tests are reported a few hours later.
The researchers found that patients who were given morphine
had 48 percent higher risk of dying and 34 percent higher risk
of suffering another heart attack while in the hospital.
"This increase in mortality was present in every subgroup of
patients we studied," Meine said. "What we found interesting was
that patients given morphine were more likely to receive
evidence-based medicine, were more likely to be treated by a
cardiologist and were more likely to receive an invasive cardiac
procedure."
Meine recommends that physicians with hospitalized heart
attack patients should begin with nitroglycerin therapy to
control pain. Our recommendation is that patients should receive
the full dose of nitroglycerin. Based on our analysis, morphine
should be the last resort after else has been tried."
While patients with acute STEMI are at higher risk of dying
within 30 days of their hospital stay, patients with non-STEMI
actually have a higher risk of dying six months and one year
after initial hospital presentation. It is estimated that about
1.3 million Americans are hospitalized each year with non-STEMI.
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Sources
American Heart Association - scientific sessions - 6/11/04 - 10/11/04, New Orleans, LA Legal Disclaimer
The materials presented here were prepared by independent authors
under the editorial supervision of The Doctors Lounge, and do not represent a
publication of the American Heart Association. These
materials and the related activity are not sanctioned by the American
Heart Association or the commercial supporter of the
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The material presented here does not reflect the views of The Doctors
Lounge or
the companies providing unrestricted educational grants. These materials
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approved by the United States Food and Drug Administration. A qualified
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participants should verify all information and data before treating
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Copyright © 2004 The Doctors Lounge.
| Article reviewed by: |
Dr. Tamer Fouad, M.D.
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