Impact of periprocedural morphine use on mortality in STEMI patients treated with primary PCI.

BackgroundIntravenous morphine (MO) decreases the effect of all oral platelet P2Y12 receptor inhibitors in vitro and observational reports suggest that its use may be associated with larger infarct size. Yet, there are limited data available about the impact of this interaction on clinical outcomes. We studied the effect of MO on mortality in ST-segment elevation myocardial infarction (STEMI) patients treated with primary PCI using a prospective registry.MethodsOf the 1255 patients who underwent primary PCI, 397 received MO based on physician's judgment. Clopidogrel was used as P2Y12 receptor antagonist in all cases. Median follow-up time was 7.5 years with 457 deaths. To adjust for confounding, two propensity score-based procedures were performed: 1 to 1 matching (PSM, 728 cases), and inverse probability of treatment weighting (IPTW) retaining data from all patients. Primary outcome measure was time to all-cause death, whereas predischarge left ventricular ejection fraction (LVEF) was used as secondary end point.ResultsAn adequate balance on baseline covariates was achieved by both methods. We found no difference in survival as the HR (MO/no MO) was 0.98 (95% confidence interval [CI]: 0.76-1.26), p = 0.86 using PSM and 1.01 (95% CI: 0.84-1.23), p = 0.88 with IPTW. Likewise, distributions of LVEFs were similar using either methods: with PSM, median LVEFs were 50.0% (interquartile range [IQR]: 43.0%-55.3%) vs 50.0% (IQR: 42.0%-55.0%) in the no MO and MO groups, respectively (p = 0.76), whereas using IPTW, they were 50.0% (IQR: 42.5%-55.0%) vs 50.0% (IQR: 41.0%-55.0%), respectively (p = 0.86).ConclusionsOur data suggest that morphine use may have no impact on long-term mortality and on predischarge ejection fraction in STEMI patients treated with primary PCI

Influence of Venoarterial Extracorporeal Membrane Oxygenation Integrated Hemoadsorption on the Early Reversal of Multiorgan and Microcirculatory Dysfunction and Outcome of Refractory Cardiogenic Shock

Background: The purpose of this investigation was to evaluate the impact of venoarterial extracorporeal membrane oxygenation (VA–ECMO) integrated hemoadsorption on the reversal of multiorgan and microcirculatory dysfunction, and early mortality of refractory cardiogenic shock patients. Methods: Propensity score–matched cohort study of 29 pairs of patients. Subjects received either VA–ECMO supplemented with hemoadsorption or standard VA–ECMO management. Results: There was a lower mean sequential organ failure assessment score (p = 0.04), lactate concentration (p = 0.015), P(v–a)CO2 gap (p p = 0.007), and reduced delta C–reactive protein level (p = 0.005) in the hemoadsorption compared to control groups after 72 h. In–hospital mortality was similar to the predictions in the control group (62.1%) and was much lower than the predicted value in the hemoadsorption group (44.8%). There were less ECMO-associated bleeding complications in the hemoadsorption group compared to controls (p = 0.049). Overall, 90-day survival was better in the hemoadsorption group than in controls without statistical significance. Conclusion: VA–ECMO integrated hemoadsorption treatment was associated with accelerated recovery of multiorgan and microcirculatory dysfunction, mitigated inflammatory response, less bleeding complications, and lower risk for early mortality in comparison with controls

Internal validation.

Internal validation.</p

Dataset.

(CSV)</p

ROC curves for lactate as predictor.

Lactate level alone may have good predictive ability for predicting both in-hospital and 30-day mortality. ROC: Receiver Operating Characteristics; AUC: area under curve.</p

Discharge medication.

Discharge medication.</p

Calibration plot of the apparent and optimism-corrected models.

Calibration curves were created using a smoother on the scatter plot of expected versus observed risks. Differences between predicted and observed event rates were smaller in the expanded models in both apparent and optimism-corrected models, as shown by the decreased mean absolute error. The rug plots across the top of the figures show distribution of predicted risk. Also, the le Cessie-van Houwelingen-Copas-Hosmer test for global goodness of fit demonstrated better model fit in all apparent expanded logistic regression models (Table 3).</p

Analysis of variance of the expanded models.

(PDF)</p

Patient flow chart.

For details: see text. PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction.</p