Mais si la douleur ne tue pas
On ne peu pas en dire autant de la Morphine
Conclusions surprenantes
Morphine for Chest Pain Increases Death Risk
keywords : Cardiology, Heart Attack, Morphine
date : 11/10/2004
media contact : Richard Merritt , (919) 684-4148
[EMAIL PROTECTED]
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.
CRUSADE continuously gathers data from participating U.S. 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.
The CRUSADE registry is funded by Millennium Pharmaceuticals,
Cambridge, Mass., and Schering Corp, Kenilworth, N.J. Bristol-Meyers
Squibb/Sanofi Pharmaceuticals Partnership, NY, provided an
unrestricted grant in support of CRUSADE.
Note to Editors: The researchers involved in CRUSADE can only discuss
data in the aggregate, and not about specific hospitals.
Contact Source: Trip Meine , [EMAIL PROTECTED]
http://www.dukemednews.org/news/article.php?id=8243
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