Morphine and Ticagrelor Interaction in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: ATLANTIC-Morphine.

Abstract

BACKGROUND:

Morphine adversely impacts the action of oral adenosine diphosphate (ADP)-receptor blockers in ST-segment elevation myocardial infarction (STEMI) patients, and is possibly associated with differing patient characteristics. This retrospective analysis investigated whether interaction between morphine use and pre-percutaneous coronary intervention (pre-PCI) ST-segment elevation resolution in STEMI patients in the ATLANTIC study was associated with differences in patient characteristics and management.

METHODS:

ATLANTIC was an international, multicenter, randomized study of treatment in the acute ambulance/hospital setting where STEMI patients received ticagrelor 180 mg ± morphine. Patient characteristics, cardiovascular history, risk factors, management, and outcomes were recorded.

RESULTS:

Opioids (97.6% morphine) were used in 921 out of 1862 patients (49.5%). There were no significant differences in age, sex or cardiovascular history, but more morphine-treated patients had anterior myocardial infarction and left-main disease. Time from chest pain to electrocardiogram and ticagrelor loading was shorter with morphine (both p = 0.01) but not total ischemic time. Morphine-treated patients more frequently received glycoprotein IIb/IIIa inhibitors (p = 0.002), thromboaspiration and stent implantation (both p < 0.001). No significant difference between the two groups was found regarding pre-PCI ≥ 70% ST-segment elevation resolution, death, myocardial infarction, stroke, urgent revascularization and definitive acute stent thrombosis. More morphine-treated patients had an absence of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) 3 flow (85.8% vs. 79.7%; p = 0.001) and more had TIMI major bleeding (1.1% vs. 0.1%; p = 0.02).

CONCLUSIONS:

Morphine-treatment was associated with increased GP IIb/IIIa inhibitor use, less pre-PCI TIMI 3 flow, and more bleeding. Judicious morphine use is advised with non-opioid analgesics preferred for non-severe acute pain.

TRIAL REGISTRATION:

clinicaltrials.gov identifier: NCT01347580.

• Authors: Frédéric Lapostolle, Arnoud W Van't Hof, Christian W Hamm, Olivier Stibbe, Patrick Ecollan, Jean-Philippe Collet, Johanne Silvain, Jens Flensted Lassen, Wim M J M Heutz, Leonardo Bolognese, Warren J Cantor, Angel Cequier, Mohamed Chettibi, Shaun G Goodman, Christopher J Hammett, Kurt Huber, Magnus Janzon, Béla Merkely, Robert F Storey, Jur Ten Berg, Uwe Zeymer, Muriel Licour, Anne Tsatsaris, Gilles Montalescot, ATLANTIC Investigators
• Journal: American journal of cardiovascular drugs : drugs, devices, and other interventions (Am J Cardiovasc Drugs) Vol. 19 Issue 2 Pg. 173-183 (Apr 2019) ISSN: 1179-187X [Electronic] New Zealand
• PMID: 30353444 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial)

Chemical References

• Analgesics, Opioid
• Platelet Aggregation Inhibitors
• Platelet Glycoprotein GPIIb-IIIa Complex
• Morphine
• Ticagrelor

Topics

• Adult
• Aged
• Analgesics, Opioid (adverse effects)
• Female
• Humans
• Male
• Middle Aged
• Morphine (adverse effects)
• Pain (complications, drug therapy)
• Percutaneous Coronary Intervention
• Platelet Aggregation Inhibitors (adverse effects, therapeutic use)
• Platelet Glycoprotein GPIIb-IIIa Complex (antagonists & inhibitors)
• Retrospective Studies
• ST Elevation Myocardial Infarction (complications, drug therapy, surgery)
• Ticagrelor (adverse effects, therapeutic use)
• Treatment Outcome