AVOID 2: Randomized Controlled Trial of Lignocaine Versus Opioids in Myocardial Infarction
A randomised controlled trial of 308 participants with Acute Myocardial Infarction (AMI), comparing the safety, efficacy and tolerance of opioids vs lignocaine for pain relief. Lignocaine was found to be mildly less effective for chest pain relief, but was safe and better tolerated than fentanyl when used as pre-hospital analgesia in AMI cases.
Chief Investigators
Prof Dion Stub, Prof Karen Smith, Prof Karlheinz Peter, Prof Stephen Bernard
Funding source
Heart Foundation Vanguard Grant
Completed
September 2022
Background
For over a century, first line therapy for patients with AMI has been analgesia with opioids. The relief of pain is thought to reduce myocardial oxygen demand and heart rate. However, despite widespread use of opioids in AMI, there is limited evidence of clinical benefit.
Previous research from our team has included a comprehensive research program questioning the use of opioids for ischemic chest pain. Our observational data suggested an opioid dose-dependent increase in myocardial infarct size.
The LOCAL trial confirmed a significant and concerning interaction between opioids and oral antiplatelet agents, which are first line medications to treat AMI. PhD Student Dr Himawan Fernando was awarded the prestigious Ralph Reader Prize at the Cardiac Society ANZ for the study.
Read a lay summary of our group’s work in this field here on the School newsfeed.
Aim
To compare opioids with lignocaine in avoiding the adverse biochemical interaction of opioids on antiplatelet drugs, and considering lignocaine representing a safe alternative, non- opioid analgesic for ischemic chest pain.
Outputs to date
Fernando H, Nehme Z, Peter K, Bernard S, Stephenson M, Bray J, Cameron P, Ellims A, Taylor A, Kaye DM, Smith K, Stub D; AVOID investigators. Prehospital opioid dose and myocardial injury in patients with ST elevation myocardial infarction. Open Heart. 2020 Jul;7(2):e001307. doi: 10.1136/openhrt-2020-001307.
Fernando H, Duong T, Huynh K, Noonan J, Shaw J, Duffy SJ, Nehme Z, Smith K, Myles PS, Meikle PJ, Peter K, Stub D. Effects of lignocaine vs. opioids on antiplatelet activity of ticagrelor: the LOCAL trial. Eur Heart J. 2021 Oct 14;42(39):4025-4036. doi: 10.1093/eurheartj/ehab557.
Fernando H, Milne C, Nehme Z, Ball J, Bernard S, Stephenson M, Myles PS, Bray JE, Lefkovits J, Liew D, Peter K, Brennan A, Dinh D, Andrew E, Taylor AJ, Smith K, Stub D. An open-label, non-inferiority randomized controlled trial of lidocAine Versus Opioids In MyocarDial Infarction study (AVOID-2 study) methods paper. Contemp Clin Trials. 2021 Jun;105:106411. doi: 10.1016/j.cct.2021.106411.
Fernando H, Nehme Z, Dinh D, Andrew E, Brennan A, Shi W, Bloom J, Duffy SJ, Shaw J, Peter K, Nadurata V, Chan W, Layland J, Freeman M, Van Gaal W, Bernard S, Lefkovits J, Liew D, Stephenson M, Smith K, Stub D. Impact of prehospital opioid dose on angiographic and clinical outcomes in acute coronary syndromes. Emerg Med J. 2022 Apr 26:emermed-2021-211519. doi: 10.1136/emermed-2021-211519.
Fernando H, Nehme Z, Milne C, O'Brien J, Bernard S, Stephenson M, Myles P, Lefkovits J, Peter K, Brennan A, Dinh D, Andrew E, Taylor AJ, Smith K, Stub D. LidocAine Versus Opioids In MyocarDial infarction: The AVOID-2 randomised controlled trial. Heart Ling and Circulation. 2022 Jan;31(3):S211. doi: 10.1016/j.hlc.2022.06.349.
Presented as a late breaking clinical trial at Euro PCR Paris, 2022.