AHA: Increased awareness, emergency training needed in opioid-associated cardiac arrest
The American Heart Association published a scientific statement describing the pathophysiology and treatment options for people with opioid-associated out-of-hospital cardiac arrest.
In addition, the statement highlighted the importance of increased awareness and education regarding opioid use disorder.
“This evidence-based review is valuable to help improve prevention and treatment of opioid-associated out-of-hospital cardiac arrest, which primarily affects people in the prime of adult life,” Cameron Dezfulian, MD, FAHA, senior faculty in the departments of critical care and adult coronary heart disease at Texas Children’s Hospital and vice chair of the scientific statement writing group, said in a press release. “And, there are important scientific elements to be aware of since this type of cardiac arrest is fundamentally different from adult out-of-hospital sudden cardiac arrests, which have been more often studied.”
The statement details the specific indicators for opioid-associated cardiac arrest, describes how body functions are affected and provides guidance on treatment options.
Pathophysiology considerations
According to the statement published in Circulation, the pathophysiology of polysubstance toxidromes involving opioids, asphyxial death and prolonged hypoxemia leading to cardiac arrest is different from sudden cardiac arrest.
Other disease states that may be experienced by those who use opioids include bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy and pulmonary edema, the authors wrote.
According to the committee, the strongest risk factors for opioid-associated cardiac arrest include:
- history of other substance or alcohol use disorder;
- comorbid medical or mental health disorders;
- high long-term dose of opioids or use of potent synthetics;
- concurrent benzodiazepine or antidepressant use;
- being opioid-naive;
- recent incarceration or inpatient hospitalization with loss of tolerance;
- recent release from abstinence-based treatment program;
- enrollment in opioid dependence treatment program;
- history of prior opioid poisoning; and
- social factors that result in isolation.
“Different opioids bind to mu-opioid receptors with vastly differing potencies and cause analgesia, euphoria and respiratory depression to different degrees; for this reason, the risk of opioid-associated out-of-hospital cardiac arrest varies between opioids,” the committee wrote. “Some opioids, particularly methadone, cause dysrhythmias. Opioid antagonists reverse respiratory depression but can precipitate withdrawal; while not directly lethal, withdrawal has important negative effects. Most opioid-associated out-of-hospital cardiac arrest involves concomitant use of multiple sedatives.”
According to the release, opioids such as methadone can prolong the QT interval and increase risk for cardiac death; in addition, the increasing prevalence of opioid use has been associated with incidence of endocarditis.
In addition, animal studies have shown delta-opioid receptor agonism may prevent ischemic damage; however, some causes of opioid-associated out-of-hospital cardiac arrest are not reversible with opioid antagonists and require other therapy.
Naloxone or CPR for opioid overdose
“Optimizing outcomes after cardiac arrest associated with opioid overdose requires recognition of distress by another person — the lay public or emergency dispatchers, prompt emergency response and treatment with naloxone or CPR ventilation coupled with compressions,” Dezfulian said in the release.
The committee stated that emergency medical service responders, trained laypeople and the general public with 911 emergency dispatcher instructions can administer naloxone for opioid overdose to quickly reverse respiratory depression or hypoventilation and prevent cardiac arrest. Traditional CPR including airway and rescue breathing support can also be effective, according to the release.
The statement also recommended the delaying prognostication and decisions about cessation of life-saving efforts until at least 72 hours after return of spontaneous circulation and normothermia; when initial intoxicants and their metabolites have cleared the patient’s system; and when ICU-administered sedatives and analgesics have also cleared the patient’s system.
“Targeted educational campaigns providing opioid use disorder education and prevention information, naloxone distribution and conventional CPR training, including rescue breathing, to those likely to have or witness an opioid overdose could help prevent and improve treatment of opioid-associated out-of-hospital cardiac arrest,” Dezfulian said. “Along with broader public education, legal reforms and policies aimed at preventing opioid-associated cardiac arrest can save lives and should include resources for medication treatment in order to improve recovery for a generally young otherwise healthy segment of our population.”
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