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Original Research |

Morphine use in the emergency department and outcomes of patients with acute heart failure: A propensity score-matching analysis based on the EAHFE Registry

Òscar Miró, MD, PhD; Víctor Gil, MD; Francisco J. Martín-Sánchez, MD, PhD; Pablo Herrero, MD, PhD; Javier Jacob, MD, PhD; Alexandre Mebazaa, MD, PhD; Veli-Pekka Harjola, MD, PhD; José Ríos, BSc, MSc; Judd E. Hollander, MD, PhD; W. Frank Peacock, MD, PhD; Pere Llorens, MD, PhD
Author and Funding Information

Authors’ roles in the manuscript: The study was conceived by OM, VG, and PL; the design was carried out by OM, FJMS and JR; the patient inclusion was done by OM, VG, FJMS, and PL; data analysis was performed by OM, JR, VPH, and WFP; primary discussion of results was done by OM, VG, JR, VPH, JEH, and WFP; the first draft was written by OM; all the authors participated in the discussion, gave substantial input to the paper content; all the authors revised and approved the successive versions of the paper during the editorial review process, and gave approval for the final version. OM takes responsibility for the entire manuscript.

Conflict of interests: The authors state that they have no conflict of interests with the present work. The ICA-SEMES Research Group has received unrestricted support from Orion Pharma and Novartis. The present study was designed, performed, analyzed and written exclusively by the authors independently of these pharmaceutical companies. Dr. Hollander has research grant support from Alere, Trinity, Roche, and Siemens.

Other investigators of the ICA-SEMES research group: Marta Fuentes, Cristina Gil (Hospital Universitario de Salamanca). María José Pérez-durá, Eva Salvo, José Vallés (Hospital La Fe de Valencia). Rosa Escoda, Carolina Xipell, Carolina Sánchez (Hospital Clinic de Barcelona). José Pavón, Ana Bella Álvarez (Hospital Dr. Negrín de Las Palmas de Gran Canaria). Antonio Noval (Hospital Insular de Las Palmas de Gran Canaria). José M. Torres (Hospital Reina Sofía de Córdoba). Maria Luisa López-Grima, Amparo Valero (Hospital Dr. Peset de Valencia). Alfons Aguirre, MariaÀngelsPedragosa (Hospital del Mar de Barcelona). Maria Isabel Alonso, Helena Sancho, Paco Ruiz (Hospital de Valme de Sevilla). AntonioGiménez, José Miguel Franco (Hospital Miguel Servet de Zaragoza). Sergio Pardo (Hospital San Juan de Alicante). Ana BelenMecina (Hospital de Alcorcón). JosepTost (Consorci Sanitari de Terrassa). JordiFabregat, (Hospital Mutua de Terrasa). Susana Sánchez (Hospital Rio Ortega de Valladolid). Pascual Piñera (Hospital Reina Sofia de Murcia). Raquel Torres Garate (Hospital Severo Ochoa). AitorAlquezar, Miguel Alberto Rizzi (Hospital San Pau de Barcelona). Fernando Richard (Hospital de Burgos). Javier Lucas (Hospital General de Albacete). Irene Cabello, Álex Roset (Hospital Universitari de Bellvitge, Barcelona).Esther Rodríguez-Adrada, Guillermo Llopis García (Hospital Clínico San Carlos, Madrid). José Manuel Garrido (Hospital Virgen de la Macarena, Sevilla).

1Emergency Department, Hospital Clínic, Barcelona, “Emergencies: processes and pathologies” Research Group, IDIBAPS, Barcelona, Spain

2Emergency Department, Hospital Clínico San Carlos, Madrid, Universidad Complutense de Madrid, Spain

3Emergency Department, Hospital Universitario Central de Asturias, Oviedo, Spain

4Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain

5Department of Anesthesiology and Critical Care Medicine, Hospital Lariboisière, Université Paris Diderot, Paris, France

6Emergency Medicine, Helsinki University, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland

7Laboratory of Biostatistics & Epidemiology, Universitat Autonoma de Barcelona; Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain

8Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA

9Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA

10Emergency Department, Home Hospitalization and Short Stay Unit, Hospital General de Alicante, Alicante, Spain

Address for correspondence: Òscar Miró Emergency Department Hospital Clínic Villarroel 170 08036 Barcelona Catalonia, Spain.


Copyright 2017, . All Rights Reserved.


Chest. 2017. doi:10.1016/j.chest.2017.03.037
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Published online

Abstract

Objective  To determine the relationship between short-term mortality and intravenous morphine use in emergency department (ED) patients diagnosed with acute heart failure (AHF).

Methods  Consecutive AHF patients presenting to 34 Spanish EDs from 2011 to 2014 were eligible for inclusion. The subjects were divided into those with or without intravenous morphine treatment (M and WOM groups, respectively) during ED stay. The primary outcome was 30-day all-cause mortality, and secondary outcomes were mortality at different intermediate time points, in-hospital mortality, and length of hospital stay (LOS). We generated a propensity-score in order to match the M and WOM groups 1:1 according to 46 different epidemiological, baseline, clinical and therapeutic factors. We investigated independent risk factors for 30-day mortality in patients receiving morphine.

Results  We included 6516 patients (mean age: 81 (SD 10) years; 56% women): 416 (6.4%) in the M and 6100 (93.6%) in the WOM group. Overall, 635 (9.7%; M:26.7%; WOM:8.6%) died by day 30. After propensity score matching, 275 paired patients constituted each group. M patients had a higher 30-day mortality (55 [20.0%] vs. 35 [12.7%] deaths; HR: 1.66; 95%CI: 1.09-2.54; p=0.017), which was directly related to glycaemia (p=0.013) and inversely related to the baseline Barthel index and systolic blood pressure (p=0.021) at ED arrival (p=0.021). Mortality was increased at every intermediate time point, although the greatest risk was at the shortest time (at 3 days: 22[8.0%] vs. 7 [2.5%] deaths; OR: 3.33; 95%CI: 1.40-7.93; p=0.014). In-hospital mortality did not increase (39 [14.2%] vs. 26 [9.1%] deaths; OR: 1.65; 95%CI: 0.97-2.82; p=0.083) and LOS did not differ between groups (median (IQR) in M: 8(7); WOM: 8(6); p=0.79).

Conclusion  This propensity score-matched analysis suggests that the use of intravenous morphine in AHF could be associated with increased 30-day mortality.


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