Effects of midazolam vs morphine in patients with acute pulmonary edema with left ventricular systolic dysfunction: a secondary analysis of data from the MIMO trial
Alberto Domínguez-Rodríguez1,2, Daniel Hernández-Vaquero3, Coral Suero-Méndez4, Guillermo Burillo-Putze5, Victor Gil6, Rafael Calvo-Rodríguez7, Pascual Piñera-Salmerón8, Pere Llorens9, Francisco J. Martín-Sánchez10, Pedro Abreu-González11, Francesco Formica12, Òscar Miró6, en representación del Grupo de Investigadores MIMO (MIdazolam versus MOrfina)
Affiliation of the authors
1Cardiology Service, Hospital Universitario de Canarias, Universidad Europea de Canarias, Tenerife, Spain. 2CIBER cardiovascular diseases (CIBERCV), Madrid, Spain. 3Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain. University of Oviedo, Oviedo, Spain. 4Emergency Department, Hospital de la Axarquía, Málaga, Spain. 5Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain. 6Emergency Department, Hospital Clinic, Barcelona, Institut d’ Investigació Biomèdica August Pi iSunyer (IDIBAPS); University of Barcelona, Catalonia, Spain. 7Emergency Department, Hospital Universitario Reina Sofia, Córdoba, Spain. 8Emergency Department, Hospital General Universitario Reina Sofia, Murcia, Spain. 9Emergency Department, Hospital General de Alicante, Spain. 10Emergency Department, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain. 11Department of Physiology, Faculty of Medicine, University of La Laguna, Tenerife, Spain. 12University of Parma, Department of Medicine and Surgery, Parma, Italy.
Domínguez-Rodríguez A, Hernández-Vaquero D, Suero-Méndez C, Burillo-Putze G, Gil V, Calvo-Rodríguez R, et al. Effects of midazolam vs morphine in patients with acute pulmonary edema with left ventricular systolic dysfunction: a secondary analysis of data from the MIMO trial. Emergencias. 2023;35:25-30
Summary
Background and objective.
The midazolam vs morphine (MIMO) trial showed that patients treated with midazolam had fewer serious adverse events than those treated with morphine. In many patients with acute pulmonary edema, the left ventricular ejection fraction (LVEF) is preserved, at 50% or higher. We aimed to determine whether left ventricular (LV) systolic dysfunction (D), defined by an LVEF of less than 50%, modifies the protective effect of midazolam vs morphine.
Methods.
The MIMO trial randomized 111 patients with acute pulmonary edema to receive intravenous midazolam in 1-mg doses to a maximum of 3 mg (n = 55) or morphine in 2- to 4-mg doses to a maximum of 8 mg (n= 56). We calculated the relative risk (RR) for a serious adverse event in patients with and without systolic LVD.
Results.
LVEF was preserved in 84 (75.7%) of the patients with acute pulmonary edema. In patients with systolic LVD, 4 patients (26.9%) in the midazolam arm vs 6 (50%) in the morphine arm developed serious adverse events (RR, 0.53; 95% CI, 0.2-1.4). In patients without systolic LVD, 6 patients (15%) in the midazolam arm vs 18 (40.9%) in the morphine arm experienced such events (RR, 0.37; 95% CI, 0.16-0.83). The presence of systolic LVD did not modify the protective effect of midazolam on serious adverse effects (P=.57).
Conclusions.
The effect of midazolam vs morphine in protecting against the development of serious adverse events or death is similar in patients with and without systolic LVD.
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