Cardiovascular Complications of Opioid Use: JACC State-of-the-Art Review

J Am Coll Cardiol. 2021 Jan 19;77(2):205-223. doi: 10.1016/j.jacc.2020.11.002.

Abstract

Opioids are the most potent of all analgesics. Although traditionally used solely for acute self-limited conditions and palliation of severe cancer-associated pain, a movement to promote subjective pain (scale, 0 to 10) to the status of a "fifth vital sign" bolstered widespread prescribing for chronic, noncancer pain. This, coupled with rising misuse, initiated a surge in unintentional deaths, increased drug-associated acute coronary syndrome, and endocarditis. In response, the American College of Cardiology issued a call to action for cardiovascular care teams. Opioid toxicity is primarily mediated via potent μ-receptor agonism resulting in ventilatory depression. However, both overdose and opioid withdrawal can trigger major adverse cardiovascular events resulting from hemodynamic, vascular, and proarrhythmic/electrophysiological consequences. Although natural opioid analogues are devoid of repolarization effects, synthetic agents may be proarrhythmic. This perspective explores cardiovascular consequences of opioids, the contributions of off-target electrophysiologic properties to mortality, and provides practical safety recommendations.

Keywords: QT-prolongation; arrhythmia; dextromethorphan; endocarditis; hERG channel; levacetylmethadol; loperamide; methadone; mortality; opioid mortality; opioid overdose; opioid withdrawal; opioids; propoxyphene; torsade de pointes.

Publication types

  • Review

MeSH terms

  • Analgesics, Opioid / adverse effects*
  • Cardiotoxicity / etiology*
  • Cardiovascular Diseases / chemically induced*
  • Humans
  • Methadone / adverse effects*
  • Opioid-Related Disorders / complications*
  • Opioid-Related Disorders / mortality

Substances

  • Analgesics, Opioid
  • Methadone