Will intravenous paracetamol crush fentanyl in patients undergoing PCI for STEMI?

Pain relief is important in patients experiencing ST-elevation myocardial infarction (STEMI). Not only because pain management improves patient comfort, but also because pain is associated with activation of the sympathetic nervous system, causing vasoconstriction and increased workload of the heart [1]. Therefore, the 2012 STEMI guideline of the European Society of Cardiology (ESC STEMI) recommended administering titrated intravenous opioids (class I, level of evidence (LoE) C) [2]. Since then, multiple studies have shown that morphine causes slower uptake and delayed onset of action of oral antiplatelet agents leading to high platelet reactivity [3, 4]. Furthermore, it could cause nausea and vomiting, leading to the absence of any form of oral P2Y12 inhibition [1]. Therefore, the recommendation was downgraded to class IIa, LoE C, in the 2017 ESC STEMI guideline