Good afternoon, my question is related to current ACS treatment guidelines. I have had several STEMI inter-facility transfers within the last month or so where attending physicians have initiated pain management with Fentanyl. Upon receiving patient handover from these physicians they often request that this treatment modality be continued throughout transfer. Due to the current AMHA research regarding increased mortality in ACS and STEMI patients who are treated with morphine, is there any move to eliminate this contraindication from the fentanyl protocol, or to remove morphine from the ACS treatment guidelines? If a Physician requests this treatment modality (fentanyl) are we able to patch around this contraindication for fentanyl or would this go against the spirit of the protocol patching around contraindications? If the Physician has initiated treatment with Fentanyl and we have exhausted our nitro protocol or it is contraindicated will we suffer repercussions for not initiating morphine treatment even when it was requested that we do not by the sending physician? Would we require a patch to NOT treat this patient with morphine? Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?

Despite the longstanding use of opioids to alleviate discomfort and anxiety among STEMI patients, no RCTs of opioids have comprehensively examined hard clinical end points. Furthermore, there are very few clinical studies examining the use of fentanyl in STEMI patients. As such, the question as to whether opioids are of benefit has yet to be answered, let alone which opioid is better. As such, based off of what is known, morphine remains the opioid of use within the cardiac ischemia directive.

The 2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion suggests avoidance of routine I.V. opioid analgesic (eg, morphine or fentanyl) administration for STEMI related discomfort. However, selective use of opioid analgesic medications may be considered for severe pain with the goal of relieving pain and reducing anxiety (Weak Recommendation, Low-Quality Evidence). The writing group recognizes the importance of managing the significant discomfort that can be associated with STEMI. Although there might be a potential for harm, measured according to surrogate outcomes, this recommendation permits for selective use of opioid analgesics by providers in patients experiencing severe STEMI-related pain.  This is the rationale as to why morphine is to be used only in patients with severe pain related to their STEMI. We do not expect that there will be inclusion of fentanyl with the next release of updated directives

The only physician that can delegate to you is a Base Hospital Physician. If a sending physician requests that fentanyl be given, please advise them that this is outside of your directives and if they believe fentanyl will be of benefit over morphine, then a patient escort (MD or RN) from the sending hospital must accompany the patient on transport.

We request that you do not patch for fentanyl in your STEMI patient population based on the above rationale. Your medical directives state that you can administer morphine to STEMI patients if they are experiencing severe pain. SWORBHP medical council would suggest that morphine is an acceptable treatment in the case you describe and should be administered. If it is withheld, an explanation on the ACR as to why it is not being utilized helps us understand the rationale of what happened in the call and explain the variance that will be generated.

Please see the above answer for why nitro carries with it HR ranges.

Analgesia,Cardiac Ischemia,Cardiac/Circulation,Pain/Sedation/Nausea

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