SynthesisBMJ open2019
Morphine in acute coronary syndrome: systematic review and meta-analysis.
Synthesis in BMJ open, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers, 2 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
12 citing papers in PubMed, 2 syntheses or guidelines pooled it, 41 citations in OpenAlex.
- Efficacy and Harms of Opioid Analgesics for Acute Pain: Overview of Systematic Reviews and Meta-analyses.Drugs · 2026Pooled it
- Pooled it
- Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study.Scandinavian journal of trauma, resuscitation and emergency medicine · 2020Trial
- Variation in prehospital ACS care within a single city: a bicentric observational study (MONAH-1 subgroup analysis).BMC emergency medicine · 2026Observational
- Opioids in Critically Ill Acute Myocardial Infarction Patients: A Retrospective Analysis of the MIMIC-IV Database.Journal of general internal medicine · 2025Article
- Opioid addiction: A new risk factor for adverse events after endoscopic retrograde cholangiopancreatography?Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology · 2025Article
- Oral P2YEuropean cardiology · 2025Review
- Negative Impact of ST-Segment Elevation Myocardial Infarction and Morphine Dose on Ticagrelor Uptake and Pharmacodynamics: A Population PK/PD Analysis of Pooled Individual Participant Data.Clinical pharmacokinetics · 2023Article
- Outcomes of Patients with Opioid-Related Diagnoses in Acute Coronary Syndrome: a National Inpatient Sample-Based Analysis.Journal of general internal medicine · 2023Article
- Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature.ESC heart failure · 2021Review
- Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021.Arquivos brasileiros de cardiologia · 2021 · on this mapArticle
- Pharmacokinetics and Pharmacodynamics of Approved and Investigational P2Y12 Receptor Antagonists.Clinical pharmacokinetics · 2020Review
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
7 authors at 1 institution in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveMorphine is frequently used in acute coronary syndrome (ACS) due to its analgesic effect, it being recommended in the main cardiology guidelines in Europe and the USA. However, controversy exists regarding its routine use due to potential safety concerns. We conducted a systematic review of randomised-controlled trials (RCTs) and observational studies to synthesise the available evidence.
designSystematic review and meta-analysis. DATA SOURCES: CENTRAL, MEDLINE, EMBASE and trial registries. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included RCTs and observational studies evaluating the impact of morphine in cardiovascular outcomes or platelet reactivity measures. DATA EXTRACTION AND SYNTHESIS: Data were screened, extracted and appraised by two independent reviewers. The data were pooled results using a random-effects model. Outcomes included in-hospital mortality, major adverse cardiovascular events (MACE), platelet reactivity (using VerifyNow) and bleeding, reported as relative risk (RR) with 95% CI. We assessed the confidence in the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We followed the Meta-analysis Of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
resultsFive RCTs and 12 observational studies were included, enrolling 69 993 participants. Pooled results showed an increased risk of in-hospital mortality (RR 1.45 [95% CI 1.10 to 1.91], low GRADE confidence), MACE (RR 1.21, 95% CI 1.02 to 1.45) and an increased platelet reactivity at 1 and 2 hours (59.37 platelet reactivity units [PRU], 95% CI 36.04 to 82.71; 68.28 PRU, 95% CI 37.01 to 99.55, high GRADE confidence) associated with morphine. We found no significant difference in the risk of bleeding. We found no differences in subgroup analyses based on study design and ACS subtype.
conclusionsMorphine was associated with an increased risk of in-hospital mortality and MACE but the high risk of bias leads to low result confidence. There is high confidence that morphine decreases the antiplatelet effect of P2Y12 inhibitors. PROSPERO REGISTRATION NUMBER: CRD42016036357.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.