Authors: Rob Hirst, Andy Neill, Dave McCreary, Chris Connolly, Becky Maxwell / Codes: ACCS LO 1, CC4, PC4, SLO1, SLO10 / Published: 05/12/2022


– Andy Neill
– Dave Mccreary

Clinical questions

– Should we give morphine or midazolam in acute heart failure? (spoiler alert: probably neither)

Paper Title

– Midazolam versus morphine in acute cardiogenic pulmonary oedema: results of a multicentre, open‐label, randomized controlled trial


– Dominguez-Rodriguez, Eur J Heart Failure 2022


– heart failure is common as you may have noticed. The work of breathing and the associated anxiety is probably not great for the old ticker. Something like an opiate has some tenuous biological rationale in that sense. Believe it or not there is some non substantial data supporting benzos in heart failure and a long (mostly archaic) legacy of using opiates in heart failure. This pits the two against each other in combinatiton with what would be considered standard treatment at this stage – nitrates, diuretics and CPAP.
– i definitely used opiates for heart failure when i first started medicine but probably not in the past 10 or 15 years. I have never used a benzo except maybe to control agitation prior to intubation.‌


– this is an RCT of about 10 EDs in spain.
– it was open label which as you can imagine is a bit of a problem
– patients got fairly standard treatment and then randomised to midaz in boluses up to 3mg or morphine in boluses up to 8mg. There was no placebo arm, they make an argument that they felt unethical not to include one of the active arms as “symptomatic” treatment. I feel this is a weak argument as we’ve all seen pts get exceleent symptomatic treatment from CPAP and GTN etc…
– primary outcome of hospital mortality which is fairly solid


– 110 pts stopped (only a little bit) early due to harm in the morphine group
– the harm was driven by cardiovascular adverse events but difficult to tease out the details. Overall the numbers are quite so small so the harm may well not be as much as suggested.


– I think this was trying to answer a question no one was asking
– midaz is not something i’ve considered and opiates left my armoury a while ago. I would have loved to see the placebo outcomes here.