Morphine in ACS & CHF

- Only real data is retrospective reviews
- No good data showing Morphine helps in any way
- Morphine reduces preload, HR and possibly afterload
- In CHF: European societies still do suggest for severe dyspnea, anxiety, pain. American Heart Failure Society says "use with caution" given the ADHERE data, while the AHA/ ACC is silent on it.

Morphine in ACS

CRUSADE (2005, Am H Jrnl): A retrospective analysis of an observational registry of NSTEMI ACS patients. Included 57,000 patients, 17,000 of which received morphine in first 24 hours. Study authors looked at outcomes in "morphine vs. no morphine," and also "morphine vs. IV nitro gtts."

- Patients treated with any morphine had a higher risk of death (OR 1.48).
- Patients treated with morphine vs. nitro gtts had the same (OR 1.5).
- Authors state this held even after propensity score matching to adjust for the severity of illness in both groups; and held across all measured subgroups

Morphine in CHF / acute pulmonary edema

ADHERE (2008, Emerg Med J): A retrospective analysis of the Acute Decompensated Heart Failure National Registry (ADHERE). Included 147,000 patients, 21,000 of which received morphine.

- Patients treated with morphine had a higher risk of death (OR 4.8)
- Also about 5 times more likely to get intubated, 3 times more likely to need ICU

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Iakobishvili Z. et al. (2011, Acute Cardiac Care). A retrospective analysis of 2,336 heart failure patients, 218 of whom received IV morphine. (This is a later study out of Israel, after ADHERE raised red flags, so morphine is used a lot less).

- Morphine associated with higher risk of death (OR 2).
- Adjusted by propensity scoring for severity, this risk of death fell (OR 1.2, not statistically significant).

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