Article Text

other Versions

Download PDFPDF
Impact of prehospital opioid dose on angiographic and clinical outcomes in acute coronary syndromes
  1. Himawan Fernando1,2,3,4,
  2. Ziad Nehme5,6,7,
  3. Diem Dinh8,
  4. Emily Andrew5,
  5. Angela Brennan8,
  6. William Shi9,10,
  7. Jason Bloom1,
  8. Stephen James Duffy1,2,8,
  9. James Shaw1,2,
  10. Karlheinz Peter1,2,
  11. Voltaire Nadurata4,
  12. William Chan1,2,9,11,12,
  13. Jamie Layland13,14,
  14. Melanie Freeman15,
  15. William Van Gaal16,
  16. Stephen Bernard1,5,6,
  17. Jeffrey Lefkovits8,17,
  18. Danny Liew8,
  19. Michael Stephenson5,8,
  20. Karen Smith5,6,7,
  21. Dion Stub1,2,8,11
  1. 1Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
  2. 2Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
  3. 3Central Clinical School, Monash University, Melbourne, Victoria, Australia
  4. 4Department of Cardiology, Bendigo Health, Bendigo, Victoria, Australia
  5. 5Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
  6. 6Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  7. 7Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
  8. 8Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  9. 9Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
  10. 10Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  11. 11Department of Cardiology, Western Health, Melbourne, Victoria, Australia
  12. 12Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
  13. 13Department of Cardiology, Peninsula Health, Melbourne, Victoria, Australia
  14. 14Monash University, Melbourne, Victoria, Australia
  15. 15Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
  16. 16Department of Cardiology, Northern Health, Melbourne, Victoria, Australia
  17. 17Royal Melbourne Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Dr Dion Stub, Cardiology, Alfred Hosp, Melbourne, VIC 3004, Australia; d.stub{at}


Background An adverse interaction whereby opioids impair and delay the gastrointestinal absorption of oral P2Y12 inhibitors has been established, however the clinical significance of this in acute coronary syndrome (ACS) is uncertain. We sought to characterise the relationship between prehospital opioid dose and clinical outcomes in patients with ACS.

Methods Patients given opioid treatment by emergency medical services (EMS) with ACS who underwent percutaneous coronary intervention (PCI) between 1 January 2014 and 31 December 2018 were included in this retrospective cohort analysis using data linkage between the Ambulance Victoria, Victorian Cardiac Outcomes Registry and Melbourne Interventional Group databases. Patients with cardiogenic shock, out-of-hospital cardiac arrest and fibrinolysis were excluded. The primary end point was the risk-adjusted odds of 30-day major adverse cardiac events (MACE) between patients who received opioids and those that did not.

Results 10 531 patients were included in the primary analysis. There was no significant difference in 30-day MACE between patients receiving opioids and those who did not after adjusting for key patient and clinical factors. Among patients with ST-elevation myocardial infarction (STEMI), there were significantly more patients with thrombolysis in myocardial infarction (TIMI) 0 or 1 flow pre-PCI in a subset of patients with high opioid dose versus no opioids (56% vs 25%, p<0.001). This remained significant after adjusting for known confounders with a higher predicted probability of TIMI 0/1 flow in the high versus no opioid groups (33% vs 11%, p<0.001).

Conclusions Opioid use was not associated with 30-day MACE. There were higher rates of TIMI 0/1 flow pre-PCI in patients with STEMI prescribed opioids. Future prospective research is required to verify these findings and investigate alternative analgesia for ischaemic chest pain.

  • acute coronary syndrome
  • acute myocardial infarct
  • emergency ambulance systems

Data availability statement

No data are available.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Handling editor Edward Carlton

  • Twitter @Ziad_Nehme1

  • Contributors DS conceived and designed this research analysis. HF, ZN, DD and DS performed the data and statistical analysis. EA, AB, WS, JB, SJD, JS, KP, VN, WC, JL, MF, WVG, SB, JL, DL, MS, KS and DS handled funding and critical review of the current manuscript for key intellectual content. The manuscript was drafted by HF and DS who are responsible for the overall content as guarantors.

  • Funding SJD’s work is supported by a National Health and Medical Research Council (NHMRC) of Australia grant (No. 1111170). DS is supported by a National Heart Foundation of Australia Future Leader Fellowship (reference no. 101908). ZN is supported by a NHMRC Early Career Fellowship (reference no. 1146809).

  • Competing interests The Melbourne Interventional Group acknowledges funding from Abbott Vascular, Astra-Zeneca, BMS and Pfizer. These companies do not have access to data and do not have the right to review manuscripts or abstracts before publication.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.