Title:Should STEMI Patients Receive Opiate Analgesia? The Morphine Paradox
Volume: 16
Issue: 5
Author(s): Mohamed Farag*, Nikolaos Spinthakis, Manivannan Srinivasan and Diana A. Gorog
Affiliation:
- Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire,United Kingdom
Keywords:
Opiates, morphine, myocardial infarction, acute coronary syndrome, platelet reactivity, antiplatelet therapy.
Abstract: Background: The very significant benefit of P2Y12 receptor inhibitor administration in patients
with ST-elevation myocardial infarction (STEMI), in reducing future ischaemic events and stent
thrombosis, is undisputed. Morphine analgesia is very frequently co-administered to these patients for
pain relief, along with antiplatelet therapy, at the time of presentation, and prior to reperfusion with
primary percutaneous coronary intervention.
Methods: Research and online content related to opiates use in STEMI was reviewed. Bibliographies of
retrieved studies were searched manually for additional studies and reviews.
Results: There is sufficient data from pharmacokinetic and pharmacodynamic studies showing that the
co-administration of morphine with oral P2Y12 receptor inhibitor results in delayed antiplatelet effects.
However, whether this results in adverse outcomes remains unclear. Data from studies reporting the
effect of morphine on clinical outcomes in STEMI are inconsistent, although they tend to be underpowered
to show an effect on hard clinical outcomes, but some clearly show a relationship between morphine
use and infarct size. Strategies to overcome the potentially significant negative impact of morphine
on platelet reactivity in STEMI are discussed.
Conclusion: Whilst clearly definitive, adequately powered, randomised controlled trials are lacking, we
would recommend avoiding the combination of morphine with oral P2Y12 receptor inhibitors and recommend
alternative strategies including intravenous platelet inhibitor strategies, in high risk patients.
