Elsevier

American Heart Journal

Volume 149, Issue 6, June 2005, Pages 1043-1049
American Heart Journal

Clinical Investigation
Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative

https://doi.org/10.1016/j.ahj.2005.02.010Get rights and content

Background

Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non–ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments.

Methods

The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin.

Results

A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups.

Conclusions

Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial. (Am Heart J 2005;149:.)

Section snippets

Patients

Patients entered in the CRUSADE database from January 2001 through June 2003 were evaluated for this analysis. CRUSADE is a multidisciplinary quality improvement initiative for acute coronary syndrome patients across 443 emergency departments and medical centers. Patients included in the CRUSADE Initiative have ischemic symptoms at rest within 24 hours prior to presentation and high-risk features including ST-segment depression ≥0.5 mm, transient ST-segment elevation 0.5-1.0 mm (lasting for <10

Morphine versus no morphine: Baseline characteristics and treatment

In this cohort of 57,039 high-risk patients with NSTE ACS, 17,003 (29·8%) patients were treated with morphine within the first 24 hours following hospital presentation. Patients who received morphine had higher incidences of ST-segment depression, transient ST-segment elevation, and positive cardiac markers (Table I).

Patients who received morphine were more likely to receive evidence-based medications and treatments than were patients who did not receive morphine. Patients receiving morphine

Discussion

We evaluated >57,000 patients presenting to US hospitals with NSTE ACS and demonstrated that patients treated with morphine had a higher risk of death and other adverse clinical outcomes even though these patients were more likely to be treated with evidence-based medications and to undergo invasive cardiac procedures. These findings persisted even when we controlled for the concomitant use of IV nitroglycerin (which may designate higher risk patients with ongoing ischemic symptoms and signs of

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CRUSADE is funded by Millennium Pharmaceuticals, Inc., and Schering Corporation. Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership provides an unrestricted grant in support of the program.

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