These authors make a brief argument regarding the inappropriateness of the commonly taught acronym of “MONA” for the initial treatment of acute coronary syndrome. It is probably the case that well-read Emergency Physicians have since moved on, but it bears repeating.
– Morphine, which has been associated with worsened outcomes in CRUSADE, but the results are confounded by other factors. Narcotics are still probably reasonable for nitrate-resistant pain.
– Oxygen, in which hyperoxia is associated with coronary vasoconstriction, exacerbates reperfusion injury and infarct size. It is currently recommended that oxygen only be used for patients who are hypoxic.
– Nitrates, suitable for the relief of anginal symptoms in selected patients.
– Aspirin, the only element of MONA proven to be strongly beneficial.
And, presumably, future trials will involve the use of newer anti-platelet and other agents in the inital treatment of ACS.
The market is ripe for a replacement acronym!
“Initial treatment of acute coronary syndromes. Is there a future for MONA acronym after the 2010 guidelines?”
http://www.ncbi.nlm.nih.gov/pubmed/21982924
Great post, your blog is consistently one of my favorites. As a prehospital provider chest pain is a daily occurrence, but here's the dilemma that's always on my mind.
Like most places, our region has morphine (via med control) on our chest pain algorithm, and while I'd gladly give it to a patient with STEMI going for urgent revascularization, if the patient presents as an NSTEMI/UA and won't be going for a cath I can't convince myself to request it. From my understanding of the lit out there, there's plenty of rationale for moprhine supposedly vasodilating coronary vessels or decreasing the workload of the heart, but the only decent outcome data I've come across is from the analysis of the CRUSADE registry that you mentioned. Although it's true that confounding could account for the results, they still match up very well with my concern that while morphine will relieve ischemic chest pain, that is because it relieves (almost) all pain. What we end up with is a heart whose coronary bloodflow is still compromised, but the patient just isn't symptomatic and thus may not recieve maximal medical therapy and perhaps a cath sooner that may be warranted.
Perhaps someday that will be fine when everyone's getting cardiac MRI's in the ED to check for ischemia, but in today's world where chest pain patients are often managed based on their symptoms (or at least that's the impression I've gotten from my community ED), I'd hate to blunt the one useful tool to gauge how much treatment the patient requires.
Anyway, I'm curious to hear your take on this matter, and while you may be comfortable giving morphine to nitrate resistant chest pain because you can still advocate for more aggressive treatment, in my experience if I resolved a patient's chest pain in the field with morphine, they would then be classified as low risk and stuck in the corner since their ischemic symptoms "resolved."
Great post, your blog is consistently one of my favorites. As a prehospital provider chest pain is a daily occurrence, but here's the dilemma that's always on my mind.
Like most places, our region has morphine (via med control) on our chest pain algorithm, and while I'd gladly give it to a patient with STEMI going for urgent revascularization, if the patient presents as an NSTEMI/UA and won't be going for a cath I can't convince myself to request it. From my understanding of the lit out there, there's plenty of rationale for moprhine supposedly vasodilating coronary vessels or decreasing the workload of the heart, but the only decent outcome data I've come across is from the analysis of the CRUSADE registry that you mentioned. Although it's true that confounding could account for the results, they still match up very well with my concern that while morphine will relieve ischemic chest pain, that is because it relieves (almost) all pain. What we end up with is a heart whose coronary bloodflow is still compromised, but the patient just isn't symptomatic and thus may not recieve maximal medical therapy and perhaps a cath sooner that may be warranted.
Perhaps someday that will be fine when everyone's getting cardiac MRI's in the ED to check for ischemia, but in today's world where chest pain patients are often managed based on their symptoms (or at least that's the impression I've gotten from my community ED), I'd hate to blunt the one useful tool to gauge how much treatment the patient requires.
Anyway, I'm curious to hear your take on this matter, and while you may be comfortable giving morphine to nitrate resistant chest pain because you can still advocate for more aggressive treatment, in my experience if I resolved a patient's chest pain in the field with morphine, they would then be classified as low risk and stuck in the corner since their ischemic symptoms "resolved."
Thanks for the compliments! It's fun to know someone besides my mother reads this….
As far as out-of-hospital treatment goes, it seems the real issue is that your providers on the back end aren't taking chest pain seriously enough if it resolves en route with treatment. I definitely can't advocate for transporting someone without relief for their ischemic (or non-ischemic) chest pain, but I sympathize that you're concerned your patients are triaged inappropriately because their chest pain has resolved.
Thanks for the compliments! It's fun to know someone besides my mother reads this….
As far as out-of-hospital treatment goes, it seems the real issue is that your providers on the back end aren't taking chest pain seriously enough if it resolves en route with treatment. I definitely can't advocate for transporting someone without relief for their ischemic (or non-ischemic) chest pain, but I sympathize that you're concerned your patients are triaged inappropriately because their chest pain has resolved.
Thanks for the reply. I was catching up on my backlog of podcasts the other night and was pleasantly surprised to hear you on ERCAST. Well done! It's nice to see your blog getting such recognition when it's only been around a few months. You always have a nice selection of articles that are actually clinically useful with concise, well-reasoned summaries. I think I've said it before, but thanks for the great resource.
Thanks for the reply. I was catching up on my backlog of podcasts the other night and was pleasantly surprised to hear you on ERCAST. Well done! It's nice to see your blog getting such recognition when it's only been around a few months. You always have a nice selection of articles that are actually clinically useful with concise, well-reasoned summaries. I think I've said it before, but thanks for the great resource.