Background/Introduction: Acute heart failure is a common diagnosis encountered among patients presenting to the Emergency Department with complaints of shortness of breath. The emergency treatment of these patients has traditionally focused on alleviation of their symptoms of breathlessness and anxiety in addition to optimization of hemodynamics and rapid reduction in both preload and afterload. The treatment of associated symptoms has often included the administration of morphine, which has been posited to have both beneficial physiologic (vasodilation, reduction of preload) and central nervous system (reduction of breathlessness, anxiety, and pain) effects. However, recent experimental and experiential data have pointed to morphine’s potential for effecting negative physiological and CNS responses, thereby raising the possibility of increasing patient morbidity and/or mortality. Additionally, no large randomized controlled trials have been conducted to study the potential risks and benefits of morphine administration in patients presenting with acute heart failure. Despite these factors, a contingent of Emergency Physicians continue to routinely use morphine in the treatment of patients presenting with acute heart failure. Read more →
Tag Archive for: Morphine
Background: Typical medical treatment of ACS patients include dual antiplatelet therapy (DAPT) and revascularization with primary percutaneous coronary intervention (PPCI). Nitroglycerin is first line therapy in the treatment of pain in ACS with morphine as a common adjunct. Morphine helps relieve pain which decreases catecholamines and oxygen demand. We have written about the use of Morphine in ACS before on REBEL EM and advocated for fentanyl over morphine for pain control in patients with refractory pain to IV nitroglycerin. However, two new trials have been published in the past month: An observational trial in 300 patients with STEMI receiving morphine and a randomized trial using fentanyl which requires us to revisit the use of opioids in ACS. Read more →
Background: Morphine is a commonly used medication in acute coronary syndromes (ACS) to help relieve pain which in turn can help reduce sympathetic tone. Over the past few years however, there has been some concern raised about the drug-drug interactions with antiplatelet agents causing impaired platelet inhibition as well as an association with worsened clinical outcomes. P2Y12 receptor antagonists (i.e. Clopidogrel, Pasugrel, Ticagrelor) are typically administered with aspirin (dual anti-platelet therapy) as one of the cornerstones of treatment for ACS. This drug-to-drug interaction can cause delayed inhibition of platelet activation and potentially worsen clinical outcomes. Read more →
Background: Intravenous morphine use has been reported in nearly one of seven patients hospitalized with acute decompensated heart failure (ADHF). I have anecdotally, even seen physicians giving morphine as a “first-line” agent: Nitroglycerine, Non-Invasive Positive Pressure Ventilation (NIPPV), and Morphine. There is surprisingly little evidence supporting routine use of morphine in ADHF, and no major American cardiology or emergency medicine society has really endorsed or published any recommendations on the treatment of ADHF with morphine.
Most of us were taught the acronym “MONA,” Morphine, Oxygen, Nitroglycerin, and Aspirin for treatment of acute pulmonary edema and commonly, quoted physiologic/clinical beliefs for the use of morphine in ADHF are: beneficial hemodynamic effects, managing anxiety/agitation in air hunger, reduction in preload, and maybe to a lesser extent, afterload, and finally, decreasing heart rate. We should also consider the use of morphine in a framework of risk and benefit. For example intravenous morphine can also have some deleterious effects like causing central nervous system suppression, ventilatory depression, and hypotension.
The Acute Decompensated Heart Failure National Registry (ADHERE) is a large multicenter registry that records data from patients hospitalized with ADHF with more than 175,000 hospitalizations from over 250 hospitals across America. To be included in this registry patients must be >18years of age, admitted to an acute care hospital and receive a discharge diagnosis of ADHF. Data for this registry are collected by retrospective chart review and entered via an electronic web-based case report form for all consecutive eligible patients. Read more →