Time-honored treatments for the initial management of acute coronary syndromes: Challenging the status quo

Morphine, oxygen, and nitrates are time-honored therapies for the initial management of acute coronary syndrome (ACS). The traditional goal of these agents in ACS has been to (1) relieve symptoms, (2) prevent infarction or limit its size, and (3) improve outcomes, both acutely and during follow-up. Despite their ongoing use in routine ACS care, nitrates, morphine, and oxygen have no evidence of clinical outcomes benefit from randomized trials. Furthermore, emerging data have recently suggested that, in certain situations, morphine and oxygen may actually be associated with harm in the setting of ACS. In this review article, we thoroughly examine updated evidence for each of these acute-phase ACS agents with respect to their individual risks and benefits. We review guideline recommendations for these therapies and outline future directions for their use in clinical practice.