Opiates are the traditional
analgesics used in patients with
ST-elevation myocardial infarction (
STEMI). Pharmacodynamic studies indicate that
opiates delay the absorption of orally administered P2Y12 inhibitors and the onset of platelet inhibition. Whether these negative effects on platelet inhibition have an impact on clinical outcomes is unclear. A systematic review and meta-analysis was performed searching PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials to identify studies comparing
morphine and no-
morphine treatment in
STEMI patients undergoing primary
percutaneous coronary intervention. The primary end point was the occurrence of in-hospital
myocardial infarction, and secondary end points were in-hospital
stroke and death. Four observational studies were identified, including 3,220 patients with
STEMI.
Morphine-treated patients had a higher unadjusted rate of reinfarction compared with patients not receiving
morphine (1.5% vs. 0.67%, odds ratio (OR) 2.41; 95% confidence interval (CI), 1.11-5.21; P = 0.03). Unadjusted mortality rate was lower in
morphine-treated patients (1.7% vs. 4.2%, OR 0.43, 95% CI, 0.23-0.81; P = 0.009). Exclusion of the study with baseline differences between groups showed more frequent reinfarction in the
morphine group, but this was no longer statistically significant (1.3% vs. 0.5%, OR 2.02; 95% CI, 0.39-10.43; P = 0.40). There was no difference in
stroke according to
morphine treatment. Patients pretreated with
morphine appear to have a higher rate of reinfarction than patients not receiving
morphine. This may be attributable to
opiate-related delay in P2Y12 inhibitor absorption and resultant delay in onset of platelet inhibition. These concerning findings indicate the need for prospective, randomized trials to assess the impact of
opiates on clinical outcomes in
STEMI.