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Review
. 2016 Dec 19;12(12):CD007160.
doi: 10.1002/14651858.CD007160.pub4.

Oxygen therapy for acute myocardial infarction

Juan B Cabello  1 , Amanda Burls  2 , José I Emparanza  3 , Susan E Bayliss  4 , Tom Quinn  5
Affiliations
Review

Oxygen therapy for acute myocardial infarction

Juan B Cabello et al. Cochrane Database Syst Rev. .

Abstract

Background: Oxygen (O2) is widely used in people with acute myocardial infarction (AMI). Previous systematic reviews concluded that there was insufficient evidence to know whether oxygen reduced, increased or had no effect on heart ischaemia or infarct size. Our first Cochrane review in 2010 also concluded there was insufficient evidence to know whether oxygen should be used. Since 2010, the lack of evidence to support this widely used intervention has attracted considerable attention, prompting further trials of oxygen therapy in myocardial infarction patients. It is thus important to update this Cochrane review.

Objectives: To assess the effects of routine use of inhaled oxygen for acute myocardial infarction (AMI).

Search methods: We searched the following bibliographic databases on 6 June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO) and Web of Science (Thomson Reuters). LILACS (Latin American and Caribbean Health Sciences Literature) was last searched in September 2016. We also contacted experts to identify eligible studies. We applied no language restrictions.

Selection criteria: Randomised controlled trials in people with suspected or proven AMI (ST-segment elevation myocardial infarction (STEMI) or non-STEMI) within 24 hours after onset, in which the intervention was inhaled oxygen (at normal pressure) compared to air, regardless of co-therapies provided to participants in both arms of the trial.

Data collection and analysis: Two authors independently reviewed the titles and abstracts of identified studies to see if they met the inclusion criteria and independently undertook the data extraction. We assessed the quality of studies and the risk of bias according to guidance in the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was death. The measure of effect used was the risk ratio (RR) with a 95% confidence interval (CI). We used the GRADE approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro) to import data from Review Manager 5 and create 'Summary of findings' tables.

Main results: The updated search yielded one new trial, for a total of five included studies involving 1173 participants, 32 of whom died. The pooled risk ratio (RR) of all-cause mortality in the intention-to-treat analysis was 0.99 (95% CI 0.50 to 1.95; 4 studies, N = 1123; I2 = 46%; quality of evidence: very low) and 1.02 (95% CI 0.52 to 1.98; 4 studies, N = 871; I2 = 49%; quality of evidence: very low) when only analysing participants with confirmed AMI. One trial measured pain directly, and two others measured it by opiate usage. The trial showed no effect, with a pooled RR of 0.97 for the use of opiates (95% CI 0.78 to 1.20; 2 studies, N = 250). The result on mortality and pain are inconclusive. There is no clear effect for oxygen on infarct size (the evidence is inconsistent and low quality).

Authors' conclusions: There is no evidence from randomised controlled trials to support the routine use of inhaled oxygen in people with AMI, and we cannot rule out a harmful effect. Given the uncertainty surrounding the effect of oxygen therapy on all-cause mortality and on other outcomes critical for clinical decision, well-conducted, high quality randomised controlled trials are urgently required to inform guidelines in order to give definitive recommendations about the routine use of oxygen in AMI.

PubMed Disclaimer

Conflict of interest statement

None on starting this review. After starting this systematic review two of the authors (AB and TQ) have put together, with other clinical colleagues, a proposal for a randomised controlled trial in the UK of oxygen for AMI in the pre‐hospital setting. This proposal was not supported, and therefore the protocol was cancelled.

Tom Quinn was a member of the steering group for the STREAM Trial (Boehringer Ingelheim) and the EUROMAX trial (Medicines Company), and he was a local collaborator/principal investigator for the ATLANTIC trial (Astra Zeneca). All of these were studies of pre‐hospital management of patients with acute coronary syndrome.

Figures

1
1
Study flow diagram with previous included studies incorporated into the results of the updated literature search.
2
2
Study flow diagram (cumulative searches)
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Oxygen versus air, Outcome 1 All‐cause mortality in hospital for participants with AMI (fixed‐effect).
1.2
1.2. Analysis
Comparison 1 Oxygen versus air, Outcome 2 All‐cause mortality in hospital for participants with AMI (random‐effects).
1.3
1.3. Analysis
Comparison 1 Oxygen versus air, Outcome 3 All‐cause mortality in hospital for all participants (including those who did not have an AMI) (fixed‐effect).
1.4
1.4. Analysis
Comparison 1 Oxygen versus air, Outcome 4 All‐cause mortality in hospital for all participants (including those who did not have an AMI)(random‐effects).
1.5
1.5. Analysis
Comparison 1 Oxygen versus air, Outcome 5 All‐cause mortality in hospital for all participants (including those who did not have an AMI) and including Wilson trial‐ worse case analysis).
1.6
1.6. Analysis
Comparison 1 Oxygen versus air, Outcome 6 All‐cause mortality in hospital for all participants (including those who did not have an AMI and including Wilson trial‐ best case analysis ).
1.7
1.7. Analysis
Comparison 1 Oxygen versus air, Outcome 7 All‐cause mortality in hospital for all participants (including those who did not have AMI and including the two participants of Ranchord study with cardiogenic shock who died). Worse‐case analysis..
1.8
1.8. Analysis
Comparison 1 Oxygen versus air, Outcome 8 All‐cause mortality in hospital for all participants (including those who did not have AMI and including the two participants of Ranchord study with cardiogenic shock who died). Best‐case analysis.
1.9
1.9. Analysis
Comparison 1 Oxygen versus air, Outcome 9 All‐cause mortality in hospital for all participants (including those who did not have an AMI) trials done in the revascularisation era.
1.10
1.10. Analysis
Comparison 1 Oxygen versus air, Outcome 10 Cardiac failure.
1.11
1.11. Analysis
Comparison 1 Oxygen versus air, Outcome 11 Recurrent myocardial infarction (or ischaemia).
1.12
1.12. Analysis
Comparison 1 Oxygen versus air, Outcome 12 Opiate use (as a proxy measure for pain) for participants with an AMI (fixed‐effect).
1.13
1.13. Analysis
Comparison 1 Oxygen versus air, Outcome 13 Opiate use (as a proxy measure for pain) for participants with an AMI (random‐effects).
1.14
1.14. Analysis
Comparison 1 Oxygen versus air, Outcome 14 Opiate use (as a proxy measure for pain) for all participants on ITT (including those who did not have an AMI) (fixed‐effect).
1.15
1.15. Analysis
Comparison 1 Oxygen versus air, Outcome 15 Opiate use (as a proxy measure for pain) for all participants on ITT (including those who did not have an AMI) (random‐effects).
1.16
1.16. Analysis
Comparison 1 Oxygen versus air, Outcome 16 Major bleeding.
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References

References to studies included in this review

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References to ongoing studies

ACTRN12609000466246 {unpublished data only}
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