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Although, the recommendation for [[morphine]] induced pain relief has been reduced to a Class IIa recommendation for patient with [[Unstable angina|unstable angina pectoris]] (UA) and [[Non ST Elevation Myocardial Infarction]] ([[NSTEMI]]), the use of opiate analgesics (e.g. morphine) remains a Class I recommendation for patients with [[STEMI]]. | Although, the recommendation for [[morphine]] induced pain relief has been reduced to a Class IIa recommendation for patient with [[Unstable angina|unstable angina pectoris]] (UA) and [[Non ST Elevation Myocardial Infarction]] ([[NSTEMI]]), the use of opiate analgesics (e.g. morphine) remains a Class I recommendation for patients with [[STEMI]]. | ||
==Analgesic | ==Analgesic Agents that are Contraindicated in STEMI== | ||
In contrast to [[morphine]] and [[ST elevation myocardial infarction aspirin therapy|aspirin]], [[cyclooxygenase-2]] ([[COX-2]]) inhibitors and other [[non steroidal anti inflammatory drugs]] should be discontinued immediately in the setting of [[STEMI]] in so far as they inhibit [[aspirin]] and because they have been associated with an increased risk of cardiovascular events. <ref>C. Michael Gibson, Yuri B. Pride, Philip E. Aylward, Jacques J. Col, Shaun G. Goodman, Dietrich Gulba, Mijo Bergovec, Vijayalakshmi Kunadian, Cafer Zorkun, Jacqueline L. Buros, Sabina A. Murphy and Elliott M. Antman.Association of non-steroidal anti-inflammatory drugs with outcomes in patients with ST-segment elevation myocardial infarction treated with fibrinolytic therapy: an ExTRACT-TIMI 25 analysis. [http://www.springerlink.com/content/7018386828102397/?p=af9fdade1d8b42da8c3b3922acb7748b&pi=1 DOI10.1007/s11239-008-0264-4].</ref> <ref name="pmid16675319">{{cite journal |author=Gaziano JM, Gibson CM |title=Potential for drug-drug interactions in patients taking analgesics for mild-to-moderate pain and low-dose aspirin for cardioprotection |journal=Am. J. Cardiol. |volume=97 |issue=9A |pages=23–9 |year=2006 |month=May |pmid=16675319 |doi=10.1016/j.amjcard.2006.02.020 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(06)00218-9}}</ref> [[Non-steroidal anti-inflammatory drugs]] ([[NSAIDs]]) bind to a [[serine]] residue and thereby block aspirin's access [[cyclooxygenase-1]], through interference with the prostaglanin system they may worsen [[hypertension]] or [[congestive heart failure]]. In a non-randomized analysis from the EXTRACT trial, administration of a NSAID within 7 days of enrollment was associated with a higher incidence of 30-day death or nonfatal [[recurrent MI]] (15.9% vs. 10.8%, p < 0.001). | In contrast to [[morphine]] and [[ST elevation myocardial infarction aspirin therapy|aspirin]], [[cyclooxygenase-2]] ([[COX-2]]) inhibitors and other [[non steroidal anti inflammatory drugs]] should be discontinued immediately in the setting of [[STEMI]] in so far as they inhibit [[aspirin]] and because they have been associated with an increased risk of cardiovascular events. <ref>C. Michael Gibson, Yuri B. Pride, Philip E. Aylward, Jacques J. Col, Shaun G. Goodman, Dietrich Gulba, Mijo Bergovec, Vijayalakshmi Kunadian, Cafer Zorkun, Jacqueline L. Buros, Sabina A. Murphy and Elliott M. Antman.Association of non-steroidal anti-inflammatory drugs with outcomes in patients with ST-segment elevation myocardial infarction treated with fibrinolytic therapy: an ExTRACT-TIMI 25 analysis. [http://www.springerlink.com/content/7018386828102397/?p=af9fdade1d8b42da8c3b3922acb7748b&pi=1 DOI10.1007/s11239-008-0264-4].</ref> <ref name="pmid16675319">{{cite journal |author=Gaziano JM, Gibson CM |title=Potential for drug-drug interactions in patients taking analgesics for mild-to-moderate pain and low-dose aspirin for cardioprotection |journal=Am. J. Cardiol. |volume=97 |issue=9A |pages=23–9 |year=2006 |month=May |pmid=16675319 |doi=10.1016/j.amjcard.2006.02.020 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(06)00218-9}}</ref> [[Non-steroidal anti-inflammatory drugs]] ([[NSAIDs]]) bind to a [[serine]] residue and thereby block aspirin's access [[cyclooxygenase-1]], through interference with the prostaglanin system they may worsen [[hypertension]] or [[congestive heart failure]]. In a non-randomized analysis from the EXTRACT trial, administration of a NSAID within 7 days of enrollment was associated with a higher incidence of 30-day death or nonfatal [[recurrent MI]] (15.9% vs. 10.8%, p < 0.001). | ||
==Mechanism of Benefit of Morphine Sulfate== | ==Morphine== | ||
===Mechanism of Benefit of Morphine Sulfate=== | |||
The mechanisms of benefit of morphine sulfate include the following: | The mechanisms of benefit of morphine sulfate include the following: | ||
*Reduction in the hyperadrenergic state which in turn: | *Reduction in the hyperadrenergic state which in turn: | ||
**Reduces the [[pulse]] and thereby reduces oxygen consumption | |||
**Reduces the systolic blood pressure ([[afterload]]) and thereby reduces cardiac workload | |||
**Increases the threshold for [[ventricular fibrillation]] | |||
**Reduces metabolic demands and therefore cardiac workload | |||
**Reduces the work of breathing | |||
*Reduces [[preload]] and [[pulmonary capillary wedge pressure]] | *Reduces [[preload]] and [[pulmonary capillary wedge pressure]] | ||
==Clinical Trial Data Supporting Morphine Administration== | ===Clinical Trial Data Supporting Morphine Administration=== | ||
While there is no large scale clinical trial data demonstrating an improvement in mortality or other hard clinical endpoints associated with analgesic administration, analgesic agents do relieve anxiety and apprehension, both of which can heighten pain perception. Morphine may reduce the pulmonary capillary wedge pressure and make breathing easier improving the patient's quality of life. | While there is no large scale clinical trial data demonstrating an improvement in mortality or other hard clinical endpoints associated with analgesic administration, analgesic agents do relieve anxiety and apprehension, both of which can heighten pain perception. Morphine may reduce the pulmonary capillary wedge pressure and make breathing easier improving the patient's quality of life. | ||
==Dosing of Morphine== | ===Dosing of Morphine=== | ||
[[Morphine sulfate]] (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) | [[Morphine sulfate]] (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) | ||
==Side Effects of Morphine== | ===Side Effects of Morphine=== | ||
Adverse effects can be seen in patients with morphine sensitivity. | Adverse effects can be seen in patients with morphine sensitivity. | ||
* | * Hypotension: [[Hypotension]] can be minimized by keeping the patient supine. If the [[systolic blood pressure]] drops below 100 mm Hg, then the lower extremities can be elevated. | ||
* | * Vagomimetic Effects such as [[bradycardia]]: Morphine can heighten vagal tone, and administration of a vagolytic agent such as intravenous [[atropine]] in doses of 0.5- to 1.5-mg doses intravenously may be helpful in reducing the excessive vagomimetic effects of morphine. The administration of atropine should be reserved for those patients in whom [[bradycardia]] or [[hypotension]] are present. | ||
* | * Respiratory depression: Respiratory rate and depth should be monitored. The narcotic reversing agent [[naloxone]], 0.1 to 0.2 mg intravenously, can be given initially if indicated and repeated after 15 minutes if necessary. | ||
* | * [[Nausea]] and [[Vomiting]]: May be treated with [[phenothiazines]]. | ||
==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>== | ==2007 Focused Update of the 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT) <ref name="pmid15289388">{{cite journal| author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M et al.| title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). | journal=Circulation | year= 2004 | volume= 110 | issue= 5 | pages= 588-636 | pmid=15289388 | doi=10.1161/01.CIR.0000134791.68010.FA | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15289388 }} </ref><ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>== | ||
{|class="wikitable" | {|class="wikitable" | ||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Morphine sulfate]] (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the analgesic of choice for management of pain associated with [[STEMI]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Morphine sulfate]] (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the [[analgesic]] of choice for management of pain associated with [[STEMI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients routinely taking [[NSAID]]s (except for aspirin), both nonselective as well as [[COX-2]] selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, [[reinfarction]], [[hypertension]], [[heart failure]], and [[myocardial rupture]] associated with their use. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients routinely taking [[NSAID]]s (except for aspirin), both nonselective as well as [[COX-2]] selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, [[reinfarction]], [[hypertension]], [[heart failure]], and [[myocardial rupture]] associated with their use. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|} | |} | ||
| Line 50: | Line 52: | ||
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm) | |colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm) | ||
|- | |- | ||
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[NSAID]]s (except for [[aspirin]]), both nonselective as well as [[COX-2]] selective agents, should not be administered during hospitalization for [[STEMI]] because of the increased risk of mortality, [[reinfarction]], [[hypertension]], [[heart failure]], and [[myocardial rupture]] associated with their use. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[NSAID]]s (except for [[aspirin]]), both nonselective as well as [[COX-2]] selective agents, should not be administered during hospitalization for [[STEMI]] because of the increased risk of mortality, [[reinfarction]], [[hypertension]], [[heart failure]], and [[myocardial rupture]] associated with their use. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|} | |} | ||
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{{reflist|2}} | {{reflist|2}} | ||
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[[Category:Ischemic heart diseases]] | |||
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Latest revision as of 16:49, 7 November 2016
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ST Elevation Myocardial Infarction Microchapters |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Although, the recommendation for morphine induced pain relief has been reduced to a Class IIa recommendation for patient with unstable angina pectoris (UA) and Non ST Elevation Myocardial Infarction (NSTEMI), the use of opiate analgesics (e.g. morphine) remains a Class I recommendation for patients with STEMI.
Analgesic Agents that are Contraindicated in STEMI
In contrast to morphine and aspirin, cyclooxygenase-2 (COX-2) inhibitors and other non steroidal anti inflammatory drugs should be discontinued immediately in the setting of STEMI in so far as they inhibit aspirin and because they have been associated with an increased risk of cardiovascular events. [1] [2] Non-steroidal anti-inflammatory drugs (NSAIDs) bind to a serine residue and thereby block aspirin's access cyclooxygenase-1, through interference with the prostaglanin system they may worsen hypertension or congestive heart failure. In a non-randomized analysis from the EXTRACT trial, administration of a NSAID within 7 days of enrollment was associated with a higher incidence of 30-day death or nonfatal recurrent MI (15.9% vs. 10.8%, p < 0.001).
Morphine
Mechanism of Benefit of Morphine Sulfate
The mechanisms of benefit of morphine sulfate include the following:
- Reduction in the hyperadrenergic state which in turn:
- Reduces the pulse and thereby reduces oxygen consumption
- Reduces the systolic blood pressure (afterload) and thereby reduces cardiac workload
- Increases the threshold for ventricular fibrillation
- Reduces metabolic demands and therefore cardiac workload
- Reduces the work of breathing
- Reduces preload and pulmonary capillary wedge pressure
Clinical Trial Data Supporting Morphine Administration
While there is no large scale clinical trial data demonstrating an improvement in mortality or other hard clinical endpoints associated with analgesic administration, analgesic agents do relieve anxiety and apprehension, both of which can heighten pain perception. Morphine may reduce the pulmonary capillary wedge pressure and make breathing easier improving the patient's quality of life.
Dosing of Morphine
Morphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals)
Side Effects of Morphine
Adverse effects can be seen in patients with morphine sensitivity.
- Hypotension: Hypotension can be minimized by keeping the patient supine. If the systolic blood pressure drops below 100 mm Hg, then the lower extremities can be elevated.
- Vagomimetic Effects such as bradycardia: Morphine can heighten vagal tone, and administration of a vagolytic agent such as intravenous atropine in doses of 0.5- to 1.5-mg doses intravenously may be helpful in reducing the excessive vagomimetic effects of morphine. The administration of atropine should be reserved for those patients in whom bradycardia or hypotension are present.
- Respiratory depression: Respiratory rate and depth should be monitored. The narcotic reversing agent naloxone, 0.1 to 0.2 mg intravenously, can be given initially if indicated and repeated after 15 minutes if necessary.
- Nausea and Vomiting: May be treated with phenothiazines.
2007 Focused Update of the 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT) [3][4]
| Class I |
| "1. Morphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the analgesic of choice for management of pain associated with STEMI. (Level of Evidence: C)" |
| "2. Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. (Level of Evidence: C)" |
| Class III (Harm) |
| "1. NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, should not be administered during hospitalization for STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. (Level of Evidence: C)" |
Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [5]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [4]
References
- ↑ C. Michael Gibson, Yuri B. Pride, Philip E. Aylward, Jacques J. Col, Shaun G. Goodman, Dietrich Gulba, Mijo Bergovec, Vijayalakshmi Kunadian, Cafer Zorkun, Jacqueline L. Buros, Sabina A. Murphy and Elliott M. Antman.Association of non-steroidal anti-inflammatory drugs with outcomes in patients with ST-segment elevation myocardial infarction treated with fibrinolytic therapy: an ExTRACT-TIMI 25 analysis. DOI10.1007/s11239-008-0264-4.
- ↑ Gaziano JM, Gibson CM (2006). "Potential for drug-drug interactions in patients taking analgesics for mild-to-moderate pain and low-dose aspirin for cardioprotection". Am. J. Cardiol. 97 (9A): 23–9. doi:10.1016/j.amjcard.2006.02.020. PMID 16675319. Unknown parameter
|month=ignored (help) - ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.
- ↑ 4.0 4.1 Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter
|month=ignored (help) - ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter
|month=ignored (help)