Morphine Harmful in CHF

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Morphine was associated with worse short-term mortality, all other known variables being equal: 20% vs. 12.7%.

Why does this matter?
Morphine can reduce dyspnea and preload, but it can also reduce respiratory drive and adversely affect hemodynamics.  Though morphine has been traditionally used to treat patients with severe heart failure, the AHA officially recommends that morphine only be used for palliative care despite the absence of quality data either supporting or refuting its use.  There are no RCTs; some observational studies have raised concerns it may increase mortality.  So this large, rigorous propensity analysis was done to provide more evidence.  REBEL EM did this great post on ADHERE, another retrospective study that found harm associated with morphine.

I'll take a shot of nitroglycerin, a side of BiPAP, hold the morphine
This was a retrospective registry study of over 6000 patients from 34 EDs in Spain that used propensity matching to come up with 275 matched pairs of patients, with the exception of morphine administration.  They found that in the matched pairs, 30-day mortality was much higher in those who received morphine than those who did not: 20% vs. 12.7%, hazard ratio 1.66.  Also, secondary outcomes of short-term mortality were also worse across the board in those who received morphine.  Although you have to interpret this with caution and not attribute causality based on the study design, it raises significant concern over the safety of morphine for patients with acute CHF exacerbation.

Morphine Use in the ED and Outcomes of Patients With Acute Heart Failure: A Propensity Score-Matching Analysis Based on the EAHFE Registry.  Chest. 2017 Oct;152(4):821-832. doi: 10.1016/j.chest.2017.03.037. Epub 2017 Apr 12.

Peer reviewed by Thomas Davis, MD.

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