AHA Presidential Statement: The Link Between Opioid Use, CVD, and Stroke

The American Heart Association (AHA) has issued a Presidential Advisory Statement outlining recommendations and considerations for addressing the effects of opioids on cardiovascular and neurovascular health.¹

The national statistics on opioid misuse are grim. In 2018, over 67,000 people died of drug overdoses, two thirds of which were opioid related. Though the number of deaths had decreased slightly from 2017, this improvement was offset in 2020 due to COVID-19. The Centers for Disease Control and Prevention estimates that the number of deaths due to drug overdoses in 2020 was over 92,000.²

On behalf of the AHA, a committee of leading health authorities developed this statement in response to the rising epidemic and to offer guidance on opioid misuse as it relates to patients with cardiovascular disease and stroke. The recommendations and suggestions/considerations were based on evidence from a literature review of epidemiology studies, reviews, consensus statements, and guidelines as well as expert opinion.

Acute Pain Management in Patients with Cardiovascular Disease

To reduce the use of opioids in patients with cardiovascular disease and to prevent harmful drug interactions, the AHA offered the following suggestions/considerations for acute pain management:

• Acetaminophen, aspirin, and nonacetylated salicylates should be considered as alternatives to opioids for pain management in patients with cardiovascular disease and muscle or joint pain.
• Use of morphine in patients with acute coronary syndrome (ACS) may reduce the effectiveness of P2Y₁₂ receptor antagonists.
• Morphine can be used in moderation to reduce pain and anxiety in patients who experience continued pain despite alternative treatment approaches.
• In hospitalized patients with ACS, clinicians can consider coadministration of parenteral antiplatelet agents with morphine.

CPR Guidelines for Suspected Opioid Overdose

In its CPR guidelines for providing basic life support for a person with a suspected opioid overdose, the AHA emphasized activating 911 and initiating chest compressions, before administering naloxone. Emergency support should be requested immediately because it may be difficult to determine the cause of cardiac arrest, especially for the lay person, and naloxone would only be effective if the cardiac arrest was caused by an opioid overdose.

Needle Exchange Programs to Reduce the Risk of Infective Endocarditis

Infective endocarditis can be transmitted through needles that are shared and used to inject opioids. The opioid epidemic has resulted in an increase in hospitalizations from infective endocarditis and associated strokes. The AHA recommends expanding free syringe exchange programs to reduce the risk of infective endocarditis.

Fighting the Opioid Epidemic

Strategies for addressing the misuse of opioids should be undertaken at all levels.

• Within the health care workplace, professionals who manage pain in cardiovascular and stroke settings should receive training in nonopioid pain management and identifying patients with opioid use disorder. The AHA also calls for destigmatizing treatment for opioid use disorder.
• Other employers are encouraged to adopt evidence-based policies and strategies to address the opioid pandemic.
• A coordinated approach to combat opioid misuse should be adopted by federal, state, and local health and law enforcement agencies.
• Research is needed to better understand the biology of addiction and develop more effective therapies. For patients with cardiovascular disease, there are knowledge gaps in the use of nonopioid alternatives to pain management, cardiovascular manifestations of opioid withdrawal, and alternative approaches to treating pain and anxiety during cardiovascular emergencies. 

References

1. Chow SL, Sasson C, Benjamin IJ, et al; on behalf of the American Heart Association. Opioid use and its relationship to cardiovascular disease and brain health: a presidential advisory from the American Heart Association. Circulation. Published online August 19, 2021. doi:10.1161/CIR.0000000000001007.

2. US Centers for Disease Control and Prevention (CDC). Provisional drug overdose death counts.  https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Updated August 1, 2021. Accessed August 17, 2021