ST Elevation Myocardial Infarction Analgesic Therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-525-6884
Associate Editor: Cafer Zorkun, M.D., Ph.D. [2] Phone:617-525-7431
Analgesia
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. Regardless of applied therapeutic strategy, this group of patients’ continuing pain requires prompt relief.
Additionally, cyclooxygenase-2 (COX-2) inhibitors and other non steroidal anti inflammatory drugs should be discontinued immediately in the setting of STEMI for their known drug interactions, related side effects, and therefore increased risk of cardiovascular events.
Mechanism of Benefit
The hyperadrenergic state that accompanies vessel occlusion and the pain of vessel occlusion may benefit from management with analgesic agents. A hyperadrenergic state has been associated with a lower threshold for ventricular fibrillation. Morphine may act to reduce preload and afterload. Morphine may reduce metabolic needs and thereby reduce "demand ischemia". Morpine may also reduce the work of breathing, which again may reduce "demand ischemia".
Clinical Trial Data
While there is no large scale clinical trial data demonstrating an improvement in mortality or other hard endpoints associated with analgesic administration, analgesic agents do relieve anxiety and apprehension, both of which can heighten pain perception.
Dosing
Morphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals)
Side Effects
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: Intravenous atropine in doses of 0.5- to 1.5-mg doses intravenously may be helpful in reducing the excessive vagomimetic effects of morphine if significant bradycardia or hypotension occurs.
- 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.
Guidelines (DO NOT EDIT)
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. Class I (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. Class I (Level of Evidence: C)[1]
References
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
