Does opioid addiction influence clinical and angiographic outcomes in STEMI patients undergoing emergency PCI?
Afshin Amirpour1, Mohammad Kermani-Alghoraishi2, Fereshteh Sattar3, Hamidreza Roohafza1, Javad Shahabi2, Reihaneh Zavar4, Masoumeh Sadeghi1
1 Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
2 Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
3 Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
4 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||24-Sep-2021|
|Date of Acceptance||23-Feb-2022|
|Date of Web Publication||27-Jan-2023|
Dr. Fereshteh Sattar
Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, PO Box - 8158388994, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Despite recognizing the traditional coronary artery disease (CAD) risk factors, some secondary factors, such as opioid substance abuse, have to be considered. We aimed to assess the relationship between opioid consumption and emergency percutaneous coronary intervention (PCI) revascularization results, according to Thrombolysis in Myocardial Infarction (TIMI) flow and in-hospital survival outcomes in ST-elevation myocardial infarction (STEMI) patients.
Materials and Methods: This case–control study was conducted on 186 patients (93 patients in each group) with acute STEMI, who were referred to Chamran Heart Center, Isfahan, Iran. Opioid addiction was diagnosed by patients' records and confirmed by conducting an interview based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria. Patients in both groups were evaluated and compared for angioplasty results based on the TIMI flow grade and in-hospital cardiovascular events and complications.
Results: Ninety-one patients (97.84%) of each group were male, and opioid-addicted patients were younger than the non-opioid users (52.95 9.91 vs. 57.90 12.17, P = 0.003). Among the CAD risk factors, prevalence of dyslipidemia was significantly higher in non-opioid users, whereas cigarette smoking was higher in opioid-addicted patients (P < 0.050). There was no significant difference between the two groups regarding pre- and post-procedural myocardial infarction complications as well as mortality rate (P > 0.050). Also, there were no significant differences between the opioid and non-opioid users regarding TIMI flow grading, and successful PCI rate based on achieving TIMI III was 60.21% versus 59.1% in opiate-dependent and non-opioid users, respectively (P = 0.621).
Conclusion: Opioid addiction has no effects on post-PCI angiographic results and in-hospital survival outcomes in STEMI patients which undergoing emergency PCI.
Keywords: Myocardial Infarction, opioid, PCI, TIMI flow
|How to cite this article:|
Amirpour A, Kermani-Alghoraishi M, Sattar F, Roohafza H, Shahabi J, Zavar R, Sadeghi M. Does opioid addiction influence clinical and angiographic outcomes in STEMI patients undergoing emergency PCI?. Adv Biomed Res 2023;12:12
|How to cite this URL:|
Amirpour A, Kermani-Alghoraishi M, Sattar F, Roohafza H, Shahabi J, Zavar R, Sadeghi M. Does opioid addiction influence clinical and angiographic outcomes in STEMI patients undergoing emergency PCI?. Adv Biomed Res [serial online] 2023 [cited 2023 Mar 31];12:12. Available from: https://www.advbiores.net/text.asp?2023/12/1/12/368538
| Introduction|| |
Cardiovascular diseases, especially acute coronary syndrome (ACS), is currently the most common cause of death worldwide and in our country, Iran. The main and known traditional risk factors for coronary artery diseases (CADs) are diabetes mellitus, hypertension, dyslipidemia, cigarette smoking, and immobility, as well as positive family history. But since Iran is located in the main pathway of opium transit and its people use opiates as first-rated substance abuse,, it is important to know the positive and negative effects of opioids on the cardiovascular system. The prevalence rate of opium addiction is about 2%–3% among Iranian population, and it was estimated to be about 10%–20% in acute myocardial infarction (MI) patients., In addition to euphoria and relaxation, one of the most important reasons for opioid abuse in our population is misconception on the preventive and ameliorating effects of opiates in CAD risk factors such as hypertension and diabetes mellitus., However, in the world of science and research, this is also known as a challenge; and some studies have revealed worsening or null effects of opiates on CAD and its risk factors,,,,,,, whereas others believe that opioids have beneficial effects in preventing ischemic heart diseases., A recent review article revealed that opium use does not protect against or improve cardiovascular problems. In any case, knowing the relationship between opioid use and cardiovascular diseases is not the aim of this study, and we are looking at its effect on the treatment process of ACS patients.
As we know, acute ST-segment elevation myocardial infarction (STEMI) is the most important component of ACS, which requires prompt and timely treatment to establish coronary blood flow. Percutaneous coronary intervention (PCI) is considered as gold standard therapy for coronary blood flow restoration and reperfusion of ischemic myocardium, which decreases mortality and morbidity as well as increases survival in patients with STEMI.
Since there is insufficient knowledge regarding the effects of opioids on coronary reperfusion in STEMI patients, in this study, we aimed to assess the relationship between opiate consumption and PCI revascularization outcomes, according to Thrombolysis in Myocardial Infarction (TIMI) flow and in-hospital survival results on the consequences of emergency coronary angioplasty.
| Materials and Methods|| |
Study type and population
In our cross-sectional case–control research, the study population consisted of patients aged between 18 and 85 years with acute STEMI diagnosis, who were referred for primary or rescue PCI to Chamran Heart Center, Isfahan, Iran, which is the largest referral hospital in central Iran, from January 2019 to August 2019. STEMI diagnosis was based on typical chest pain with onset time less than 24 h and at least 1 mm ST-segment elevation in two or more contiguous leads and elevated cardiac biomarkers simultaneously. Patients with renal dysfunction (glomerular filtration rate 60 ml/min and less or serum creatinine above 2 mg/dl), impaired liver function, severe infection, autoimmune and inflammatory diseases, subjects had cardiac arrest and received cardiopulmonary resuscitation prior to the intervention, and patients who were treated only by medication or candidates for coronary artery bypass graft (CABG) after diagnostic CAG had been excluded from the study. Patients were classified into two groups including opioid addict group as the case group and non-opioid user as the control group. Opioid addiction was defined on the basis of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for substance dependence as regular consumption of inhalatory opium more than three times per week and/or oral opium daily. All patients in the case group consumed opioid regularly before and during hospitalization (injection as needed) for withdrawal syndrome avoidance. The control group was selected in equal number to the case group after adjusting for sex, diabetes, and cardiogenic shock. The study protocol was reviewed and approved by the Chamran Heart Center Ethics Committee, affiliated with Isfahan University of Medical Sciences. Written informed consent was obtained from all patients.
The main endpoint was revascularization outcome based on TIMI flow grade. TIMI flow grade 0 is defined as no perfusion, grade 1 as penetration without perfusion, grade 2 as partial perfusion, and grade 3 as complete perfusion. Successful PCI was also investigated by angiographic definition as residual stenosis less than 20% in the presence of grade 3 TIMI flow without major intimal dissection. All angiographic views were assessed by a blinded interventionist. The secondary endpoints that included in-hospital survival outcomes were major adverse cardiac events (MACEs) including death, MI, and ischemic stroke.
Patients' basic characteristics including age, gender, and past medical histories such as hypertension (systolic blood pressure [SBP] 140 or diastolic blood pressure [DBP] 90 or receiving antihypertensive drugs), diabetes mellitus (fasting blood sugar [FBS] 126 or random plasma glucose test 200 or hemoglobin A1c [HbA1c] 7% or receiving oral diabetic medication/insulin), dyslipidemia (total cholesterol 200 mg/dl or low-density lipoprotein [LDL] 130 mg/dl or triglyceride 150 mg/dl or high-density lipoprotein [HDL] 40 mg/dl [male] and 50 mg/dl [female] or using antihyperlipidemic agents), stroke, peripheral artery disease (defined as acute or chronic obstruction of arteries supplying the lower or upper extremities), heart failure, and current cigarette smoking were extracted from hospital record files and patient interview. Opioid consumption data were obtained by face-to-face interview and included self-reported type of substance, method of use, and dose and duration of consumption.
Angiographic and procedural basic data such as time from the onset of symptoms to the performance of PCI, level of MI, type of PCI (primary or rescue), target vessel, CAD severity, and baseline TIMI flow grade were also investigated. Electrical and mechanical cardiac complications in three time intervals, including preintervention, during the first 24 h of the intervention, and after the first 24 h of PCI until the end of hospitalization, were extracted from the patients' hospital records.
Quantitative variables were reported as mean standard deviation (SD) and number (percentages) for the categorical variables. The groups were compared using the Student's t-test for continuous variables and the Chi-square test (or Fisher's exact test if needed) for categorical variables. Odds ratio with 95% confidence interval for the association between opioid addiction and PCI angiographic results, in adjusted and non-adjusted models, was calculated. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 25 (SPSS, Inc., Chicago, IL, USA), and P values of 0.05 or less were considered statistically significant.
| Results|| |
Of the patients admitted with STEMI diagnoses during the mentioned interval, 110 had opioid consumption records. Ten of these had not undergone coronary angioplasty (World Health Organization [WHO] candidates for only medical treatment or candidates for CABG) and were excluded from the study. Seven patients who denied opioid use in the interview were also excluded. Of the remaining 93 patients who were enrolled in the study, 91 (97.84%) were male and two (2.15%) were female. The control group was randomly selected (93 patients) after sex matching [Figure 1]. Given that diabetes and cardiogenic shock have significant effects on coronary angioplasty results, the two groups were also matched for these variables.
|Figure 1: Study design. PCI = percutaneous coronary intervention, STEMI = ST-elevation myocardial infarction|
Click here to view
Opioid-addicted patients were younger than the non-opioid users (52.95 9.91 vs. 57.90 12.17, P = 0.003). The frequency distribution of basic and clinical variables in both groups is presented in [Table 1]. Among the CAD risk factors, only dyslipidemia and cigarette smoking had significant differences between the groups (P < 0.050), in such a way that prevalence of dyslipidemia was higher in non-opioid users, whereas cigarette smoking was higher in opioid-addicted patients. Hypertension prevalence was also nonsignificantly lower in the case group (P = 0.068). There were no significant differences in the prevalence of stroke, PAD, and heart failure between the two groups (P > 0.050). There was no significant difference between the two groups in hemoglobin level and platelet count (P > 0.050), but creatinine level was lower in opiate-dependent group (1.22 vs. 1.07, P = 0.006).
Opiate-dependent group patients consumed different forms of opioid, which consisted of 84 (90.32%) cases of opium (inhalation and orally), seven (7.52%) cases of methadone syrup, and two (2.15%) cases of tramadol tablets. Most commonly consumed form of opium was inhalatory with 79 (94.04%) cases. The opioid consumption doses were calculated based on gram 1.98 2.77 and morphine equivalent dose (MED) 0.29 0.40. The mean (SD) of opioid usage duration was 11.74 (9.03) years.
The time interval from the onset of pain to emergency PCI in the dependent and non-dependent groups is plotted in [Figure 2] (P > 0.050). In both groups, the most common time interval from pain onset to PCI was between 3 and 6 h.
|Figure 2: Time interval from the onset of pain to emergency PCI. PCI = percutaneous coronary intervention|
Click here to view
Since patients with coronary thrombotic lesions were receiving injectable antiplatelet drug, eptifibatide, as a IIb/IIIa inhibitor agent during angioplasty, the two groups were also compared in this regard. No difference was found between opiate-dependent group (39 [41.93%]) and non-dependent group (50 [53.76%]) (P = 0.142). The mean (SD) of the left ventricular ejection fraction (EF) was 40.22 (11.17) and 39.24 (11.86) in opiate-dependent and non-dependent groups, respectively (P = 0.223). CAD severity in most of the patients in both groups was single vessel diseases [Table 2]. There was no significant difference between groups regarding the MI level and the culprit vessel (P > 0.050) [Table 2]. The most common MI level (according to surface electrocardiogram [ECG]) in both groups was extensive anterior MI, and the most common culprit vessel in both groups was left anterior descending artery (LAD). Patients were evaluated for electrical and mechanical complications at three time intervals, before PCI, during the first 24 h after PCI, and after the first 24 h until discharge, and there was no significant difference between the two groups in any of the three time intervals (P > 0.050) [Table 3]. There was no report about mechanical complications including free wall rupture, ventricular septal rupture, severe mitral regurgitation, and tamponade.
|Table 3: Comparison of pre- and post-procedural complications and death between the two groups|
Click here to view
There were no significant differences between the opioid and non-opioid users regarding TIMI flow grading before and after the PCI and TIMI delta changes (P > 0.050) [Table 4]. Successful PCI rate based on achieving TIMI III was 60.21% versus 59.1% in opiate-dependent and non-opioid user groups, respectively (P = 0.621).
To assess the relationship between opioid consumption and successful PCI angiographic results in a binomial variable (TIMI flow = III and TIMI flow <III), odds ratio was calculated in crude and adjusted models. Results of these analyses showed that there was no significant positive or negative association between the opioid addiction and successful PCI results (according to TIMI flow III) (P > 0.050) [Table 5].
|Table 5: Association between opioid addiction and TIMI flow grade (unadjusted and adjusted hazard ratio)|
Click here to view
| Discussion|| |
Opioid substance abuse has been a major problem in many countries, and there is still a controversy about the potential benefits or harms of opiates on coronary heart disease. Previous studies have focused more on the role of opium addiction in CADs extension and MI clinical outcomes and complications. For the first time, in this study, we investigated the opioid consumption effects on post-PCI angiographic results (based on TIMI flow grading) in STEMI patients which undergoing primary or rescue coronary. Our results indicated that post-procedural TIMI flow had no significant difference in opioid-addicted patients when compared to non-opioid users. The PCI success rate (defined as TIMI flow grade III) was also almost the same in both populations, and there was no significant association between the opioid addiction and successful PCI results. In our study, opioid-dependent patients were younger than non-opioid users, and dyslipidemia was less frequent and cigarette smoking was more frequent. In Roohafza et al.'s study also, opium-dependent patients were younger and their age was lower at the cardiovascular event time. As a point of interest, they reported that opium did not improve cardiovascular risk factors or post-MI mortality and morbidity. Improved cardiac risk factors such as dyslipidemia and hypertension were found in Mirzaiepour et al.'s study, in contrast to other studies. Smoking was more common in addicted patients in most of the studies.,,,, CAD severity, MI level, and culprit vessel distribution in our study showed no prominent difference between opioid users and non-users, and most of the patients were single vessel with extensive MI and LAD involvement. These data agree with the findings of Khosoosi et al., which showed no significant difference in terms of infarction type and extension between the addicts and nonaddicts. In contrast to our results, Dehghani et al. indicated that addicted patients had a lower incidence of anterior MI that it was associated with higher primary mortality. In the study of Mirzaiepour et al., opioid addiction was a strong risk factor for arrhythmia after acute MI and the prevalence of tachycardia and atrial fibrillation was significantly higher in opioid-dependent patients. In our study, ECGs in both groups were also reviewed and there was no significant difference in dysrhythmias at any of the three follow-up intervals. In addition to dysrhythmia, we also evaluated the MI mechanical complications including ventricular septal and free wall rupture, severe mitral regurgitation, and tamponade in which on cases were occurred. Like our findings, there was a consensus among the studies in that there is no association between opioid addiction and MACE and in-hospital mortality.,,, Also, a recent study by Mousavi et al. revealed that in-hospital and 6-month outcomes in opium-addicted patients who presented with STEMI were not significantly different in comparison with non–opium-addicted patients.
Our study had some limitations. Sample size was small, and we had no follow-up period. The information on the dose and duration of opioid consumption were inaccurate, given that it was obtained from interview. Another limitation of the study is the presence of confounding variables such as family history, smoking, and hyperlipidemia.
| Conclusion|| |
According to this study, opioid addiction has no effects on post-PCI angiographic results (based on TIMI flow grading) and in-hospital survival outcomes in STEMI patients which undergoing primary or rescue PCI.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nowbar AN, Gitto M, Howard JP, Francis DP, Al-Lamee R. Mortality from ischemic heart disease. Circ Cardiovasc Qual Outcomes 2019;12:e005375.
Fruchart JC, Nierman MC, Stroes ES, Kastelein JJ, Duriez P. New risk factors for atherosclerosis and patient risk assessment. Circulation 2004;109(23 Suppl 1):III15-9.
Azarasa M, Azarfarin R, Changizi A, Alizadehasl A. Substance use among Iranian cardiac surgery patients and its effects on short-term outcome. Anesth Analg 2009;109:1553-9.
Sadr Bafghi SM, Rafiei M, Bahadorzadeh L, Namayeh SM, Soltani MH, Andishmand M. Is opium addiction a risk factor for acute myocardial infarction? Acta Med Iran 2005;43:218-22.
Sadeghian H, Sheikhvatan M, Mahmoodian M, Sheikhfathollahi M, Hakki E, Sadeghian A, et al
. Comparison of short-term clinical outcome of non-st elevation versus st elevation myocardial infarction. J Tehran Univ Heart Cent 2009;4:53-8.
Roayaei P, Aminorroaya A, Vasheghani-Farahani A, Oraii A, Sadeghian S, Poorhosseini H, et al
. Opium and cardiovascular health: A devil or an angel?. Indian Heart J 2020;72:482-90.
Bjornaas MA, Bekken AS, Ojlert A, Haldorsen T, Jacobsen D, Rostrup M, et al
. A 20-year prospective study of mortality and causes of death among hospitalized opioid addicts in Oslo. BMC Psychiatry 2008;8:8.
Asgary S, Sarrafzadegan N, Naderi GA, Rozbehani R. Effect of opium addiction on new and traditional cardiovascular risk factors: Do duration of addiction and route of administration matter? Lipids Health Dis 2008;7:42.
Azod L, Rashidi M, Afkhami-Ardekani M, Kiani G, Khoshkam F. Effect of opium addiction on diabetes. Am J Drug Alcohol Abuse 2008;34:383-388.
Khademi H, Malekzadeh R, Pourshams A, Jafari E, Salahi R, Semnani S, et al
. Opium use and mortality in Golestan cohort study: Prospective cohort study of 50, 000 adults in Iran. BMJ 2012;344:e2502.
Ebdali RT, Tabaee SS, Tabaei S. Cardiovascular complications and related risk factors underlying opium consumption. J Cell Physiol 2019;234:8487-95.
Marmor M, Penn A, Widmer K, Levin RI, Maslansky R. Coronary artery disease and opioid use. Am J Cardiol 2004;93:1295-7.
Peart JN, Gross GJ. Chronic exposure to morphine produces a marked cardioprotective phenotype in aged mouse hearts. Exp Gerontol 2004;39:1021-6.
Nakhaee S, Ghasemi S, Karimzadeh K, Zamani N, Alinejad-Mofrad S, Mehrpour O. The effects of opium on the cardiovascular system: A review of side effects, uses, and potential mechanisms. Subst Abuse Treat Prev Policy 2020;15:30.
Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, et al
. ST-segment elevation myocardial infarction. Nat Rev Dis Primers 2019;5:39.
Stebbins A, Mehta RH, Armstrong PW, Lee KL, Hamm C, Van de Werf F, et al
. A model for predicting mortality in acute ST-segment elevationmyocardial infarction treated with primary percutaneous coronary intervention: Results from the Assessment of Pexelizumab in Acute Myocardial Infarction Trial. Circ Cardiovasc Interv 2010;3:414-22.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al
. Third universal definition of myocardial infarction. Eur Heart J 2012;33:2551-67.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IVTR: Text Revision. 4th
ed. Washington, DC: American Psychiatric Pub; 2000.
The TIMI Research Group. The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. N Engl J Med 1985;312:932-6.
Roohafza H, Sadeghi M, Haghani P, Shokouh P, Sarrafzadegan N. Opium decreases the age at myocardial infarction and sudden cardiac death: A long-and short-term outcome evaluation. Arch Iran Med 2013;16:154-60.
Mirzaiepour F, Dadras M, Forood A, Najafipour H, Shokoohi M. The effect of opium addiction on arrhythmia following acute myocardial infarction. Acta Med Iran 2012;50:670-5.
Masoumi M, Shahesmaeili A, Mirzazadeh A, Tavakoli M, Zia Ali A. Opium addiction and severity of coronary artery disease: A case-control study. J Res Med Sci 2010;15:27-32.
Dehghani F, Masoomi M, Haghdoost AA. Relation of opium addiction with the severity and extension of myocardial infarction and its related mortality. Addict Health 2013;5:35-42.
Khosoosi Niaki MR, Mahdizadeh H, Farshidi F, Mohammadpour M, Salehi Omran MT. Evaluation of the role of opium addiction in acute myocardial infarction as a risk factor. Caspian J Intern Med 2013;4:585-9.
Rahimi Darabad B, Vatandust J, Pourmousavi Khoshknab MM, Hajahmadi Poorrafsanjani M. Survey of the effect of opioid abuse on the extent of coronary artery diseases. Glob J Health Sci 2014;18:83-91.
Javadi HR, Allami A, Mohammadi N, Alauddin R. Opium dependency and in-hospital outcome of acute myocardial infarction. Med J Islam Repub Iran 2014;28:122.
Sharafi A, Hosseini HRP, Jalali A, Salarifar M, Nematipour E, Shojanasab M, et al
. Opium consumption and mid-term outcome of percutaneous coronary intervention in men. J Tehran Heart Cent 2014;9:115-9.
Mousavi M, Kalhor S, Alizadeh M, Movahed MR. Opium addiction and correlation with early and six-month outcomes of presenting with ST elevation myocardial infarction treated initially with thrombolytic therapy. Am J Cardiovasc Dis 2021;11:115-23.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]