Morphine ACS CRUSADE trial

[pbruss]

SO i tracked down the paper from the CRUSADE trail on which the opinion that morphine is bad fro ACS patients and attached it. at your leisure chech it out and let me know what you think.

remember whe i read a paper I ask myself 2 things.
1. have they given me enough data to suport their conclusion?
2. will this paper change my practice?

Attachments:

CRUSADE.pdf (138.45 KB)

[kemple]

2 points, 1) they had a large N of over 17k so the inclusion population is sufficient in my opinion. 2) They don't appear differentiate the severity of disease in those that got morphine and those that didn't. This could mean those who were more sick received more morphine (as they would have worse chest pains needing more mgt than just ASA and nitro) and thus had worse outcomes. This is shown as the morphine group had a 10% higher rate of intervention and not just diagnostic cath. I agree there may appear to be some causation here but this is far from a smoking gun. I don't think it changes my practice until they prove the morphine is the cause of poor outcomes not associated with sicker patients.

[pbruss]

Spot on. A few things.

1. the patients in this study were NSTEMI so you can NOT apply to STEMI patients : "The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States"
2. this is a retrospective analysis which is weak science in my opinion.  "The CRUSADE
 Initiative is a nonrandomized, retrospective, observational registry". thus it is technically correst to say " there may be a correlation with morphine and bad outcome" but you CAN NOT say morphine causes a bad outcome. that is a very inportant distenction. the same goes for the reserch that says zofran in first trimester is bad.
3. with the being retrospective Kemple is exactly right. It is most likley that the people who got morphine were having more pain because their infarction was worse. Thus there servitity of disease was worse to begin with cause more pain which resulted in morphine use. there is some evidence of this in table one. teh morphine group did have higher rates of transient st elevation 9% in non morphine group and 12.9% in morphine group.

for me 1. they have not presented enough data to convince me their conclusion in valid 2. this will not change my practice

but that what i think i would live to hear what you think and if you have a differnet conclusion.