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APE / CHF / Chestpain and Morphines roll???

Posted By  CCF Cardio MD-SGM on February 04, 1998 at 23:06:14:

In Reply to: APE / CHF / Chestpain and Morphines roll??? posted by Rick on February 04, 1998 at 15:25:38:

: I'm really searching for information and maybe some articles to provide
  a better understanding of the use of Morphine for the treatment of Acute
  Pulmonary Edema / CHF and chestpain due to suspected AMI. I posted this
  eariler so I'd like to ask again with the hope of getting a responce!
   We currently use Morphine in conjunction with the usual diruetics,nitrates
   and oxygen for the treatment of Conjestive Heart Failure. We also use it
   in the treatment of Chestpain due to suspected AMI after nitro has been
   initiated. In some areas the physicians have related that this drug masks
   chestpain S/S and makes it difficult to diagnose AMI.  
   My question is what are the percieved benefits of Morphines use in these
   conditions and why or why should we not utilize MS in the field as a
   treatment for these conditions. We get too many mixed opinions
   on this subject and it makes it difficult to maintain an acurate reason
   that we carry this drug for the treatment of these conditions.  
   Thanks in advance for your opinion.
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1 Answers
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Avatar universal
Dear Rick,
I regret the delay in answering your question.  Morphine has many traditional uses, especially in the treatment of pain, where it falls into the class of opiod narcotic analgesics, providing some of the best pain relief known.  Apart from stimulating naturally occurring opiod receptors in the brain, causing analgesia, morphine also tends to increase venous capacitance, reducing somewhat the amount of blood being returned to the heart, and slightly decreasing the workload of the heart.  Some have argued that this results in an appreciable decrease in the oxygen demand of working cardiac muscle, and possibly helps in the management of acute coronary ischemic syndromes such as heart attack(myocardial infarction) and unstable angina.   There may be some truth to this suggestion, but most cardiologists now believe that the use of morphine in the treatment of these syndromes in flatly contraindicated.  
Because of its strong analgesic properties, as well as its anxiolytic/sedating properties, morphine can mask the pain of ongoing cardiac ischemia.   This can mislead physicians into believing that a heart attack is no longer in evolution, thus foregoing what can be lifesaving therapies such as thrombolytic medications to break up coronary blood clots, or emergency cardiac catheterization and angioplasty.   To reiterate, morphine has no role in the treatment of acute ischemic syndromes such as chest pain(angina), or suspected MI.  The only time this medicine should be used in these conditions is when a diagnosis is firmly established, and maximal therapy has already been instituted-- that would be the time when masking pain would be acceptable.  To risk minimizing ongoing angina and thus potentially deprive the patient of lifesaving therapy is a serious error.  You mentioned that you work in the field-- I would aggressively discourage the use of morphine in this setting for ischemic syndromes.  
If the diagnosis is CHF,  morphine can be helpful in reducing shortness of breath and cardiac filling pressure.  The problem is that many cases of CHF are in fact ischemic syndromes (heart attack, angina) in evolution.  The CHF results from ischemic cardiac muscle.  Once again, morphine should not be administered in this setting until the underlying cause of the congestive heart failure exacerbation is identified.  Once in the hospital, when ischemia is ruled out, morphine may be a useful adjunct to traditional CHF medications such as diuretics, vasodilators, and other medications.
Regarding the acute management of suspected coronary syndromes,  prompt administration of aspirin has been shown to save life, and nitrates and oxygen are standard therapy.  EMS personnel in Washington state have been involved in studies showing that the administration of thrombolytic therapy (Streptokinase or TPA) to patients with Acute MI on ECG results in lives saved.  This is not standard protocol at this time, however.
Hope I've been of help. Information provided in the Heart Forum is for general purposes only.  Specific diagnoses and therapies can only be provided by your physician.

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