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and 52% of patients required no morphine at all. Independent predictors of increased
morphine requirements included suspicion or confirmation of infarction, ST‐segment changes
on the admission ECG, male sex and a history of angina or cardiac failure (Everts et al, 1998
Level IV).
Morphine provided better analgesia than IV metoprolol (Everts et al, 1999 Level II) and was
associated with better cardiovascular outcomes during acute hospital admission and later
follow‐up, when compared with a fentanyl‐droperidol mixture administered early in the
treatment of patients with acute ischaemic chest pain (Burduk et al, 2000 Level II). However
a large retrospective audit reported increased mortality in patients treated with morphine,
either alone or in combination with nitroglycerine (independent of other confounders), in non‐
ST segment elevation acute coronary syndrome (Meine et al, 2005 Level III‐2). IV bolus doses of
morphine and alfentanil were equally effective in relieving acute ischaemic chest pain but the
onset of analgesia was faster with alfentanil (Silfvast & Saarnivaara, 2001 Level II). Morphine was
similar to buprenorphine (Weiss & Ritz, 1988 Level II) and pethidine (Nielsen et al, 1984 Level II) in
terms of analgesia and adverse effects. IN fentanyl and IV morphine were equally effective in
reducing acute cardiac chest pain during prehospital transfer (Rickard et al, 2007 Level II).
In patients with chest pain due to cocaine‐induced acute coronary syndrome, the addition of
IV diazepam or lorazepam to treatment with sublingual nitroglycerine provided superior
analgesia (Baumann et al, 2000 Level II; Honderick et al, 2003 Level II).
In acute coronary syndrome, hyperbaric oxygen therapy reduced time to relief of ischaemic
pain, although insufficient evidence exists to recommend its routine use (Bennett et al, 2005
Level I).
N 2O in oxygen was effective in relieving acute ischaemic chest pain, with a significant
reduction in beta‐endorphin levels (O'Leary et al, 1987 Level II).
TENS reduced the number and duration of ischaemic events during unstable angina,
however without a significant effect on pain (Borjesson et al, 1997 Level II).
NSAIDs may be useful in the treatment of acute pain in pericarditis (Schifferdecker &
Spodick, 2003).
CHAPTER 9 1. Morphine is an effective and appropriate analgesic for acute cardiac pain (U) (Level II).
Key messages
2. Nitroglycerine is an effective and appropriate agent in the treatment of acute ischaemic
chest pain (U) (Level IV).
The following tick box represents conclusions based on clinical experience and expert
opinion.
The mainstay of analgesia in acute coronary syndrome is the restoration of adequate
myocardial oxygenation, including the use of supplemental oxygen, nitroglycerine, beta
blockers and strategies to improve coronary vascular perfusion (U).
9.6.4 Acute pain associated with haematological disorders
Sickle cell disease
Sickle cell disease includes a group of inherited disorders of haemoglobin production.
Haemoglobin S polymerises when deoxygenated, causing rigidity of the erythrocytes, blood
hyperviscosity and occlusion of the microcirculation with resultant tissue ischaemia and
infarction (Niscola et al, 2009).
256 Acute Pain Management: Scientific Evidence
