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Morphine for Heart Attack Pain Linked to Risk of Death

Breaking News - May 2005 - Week 2

(May 11, 2005)

Healthcare in  the News

-- While many patients hospitalized for a heart attack have long been treated with morphine to relieve chest pain, an analysis has shown that these patients have almost a 50 percent higher risk of dying, says a report in the American Heart Journal.

Picture of female heart attack victim, clenching her chest

Researchers from the Duke Clinical Research Institute say their findings should be followed by a second study to confirm their analysis.

Meanwhile, they advise cardiologists to begin treatment with sufficient doses of nitroglycerin to relieve pain before resorting to morphine.

Study Shows Clear Evidence

The new 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 - found that those who received morphine had a 6.8 percent death rate, compared to 3.8 percent for those receiving nitroglycerin.

"The results of this analysis raise serious concerns about the safety of the routine use of morphine in this group of heart patients," says Dr. Trip Meine, the study's lead author.

"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," he notes.

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 [decreased blood flow to heart muscle]," Dr. Meine says. "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 continues.

"These side effects could explain the worse outcomes in patients whose heart function has already been compromised by disease," Dr. Meine says.

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 American Heart Association 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.

Current Standard of Care May Include Morphine

"This increase in mortality was present in every subgroup of patients we studied," Dr. Meine explains.

"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," he says.

Dr. 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," he says. "Based on our analysis, morphine should be the last resort after all else has been tried."

CRUSADE continuously gathers data from participating US hospitals on treatments for patients with non-STEMI and provides quarterly feedback to hospitals with the ultimate goal of improving adherence to the ACC/AHA treatment guidelines and patient outcomes.

Always consult your physician for more information.



For more information on health and wellness, please visit health information modules on this Web site.


Vital Signs Explained

Vital signs are measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals and healthcare providers include:

  • body temperature
  • pulse rate
  • respiration rate (rate of breathing)
  • blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.)

Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.

The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature, according to the American Medical Association, can range from 97.8°F (or Fahrenheit, equivalent to 36.5° C, or Celsius) to 99° F (37.2° C).

Fever (also called pyrexia) is defined as body temperature that is higher than normal for each individual. It generally indicates that there is an abnormal process going on within the body.

The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate heart rhythm or strength of the pulse.

The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Girls ages 12 and older and women, in general, tend to have faster heart rates than do boys and men.

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and with other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing.

Normal respiration rates for an adult person at rest range from 15 to 20 breaths per minute. Respiration rates over 25 breaths per minute or under 12 breaths per minute (when at rest) may be considered abnormal.

Blood pressure, measured with a blood pressure cuff and stethoscope by a nurse or other healthcare provider, is the force of the blood pushing against the artery walls. Each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as the heart contracts.

Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure, refers to the pressure inside the artery when the heart contracts and pumps blood through the body. The lower number, or diastolic pressure, refers to the pressure inside the artery when the heart is at rest and is filling with blood. Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of mercury).

According to the National Heart, Lung, and Blood Institute (NHLBI), high blood pressure for adults is defined as:

140 mm Hg or greater systolic pressure

and

90 mm Hg or greater diastolic pressure

In an update of NHLBI guidelines for hypertension in 2003, a new blood pressure category was added called prehypertension:

120 mm Hg - 139 mm Hg systolic pressure

and

80 mm Hg - 89 mm Hg diastolic pressure

The new NHLBI guidelines now define normal blood pressure as follows:

Less than 120 mm Hg systolic pressure

and

Less than 80 mm Hg diastolic pressure

These numbers should be used as a guide only. A single elevated blood pressure measurement is not necessarily an indication of a problem.

Always consult your physician for a diagnosis.

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