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Supplementary Oxygen in ACS

Question Type:
Intervention
Full Question:
Among adult patients with suspected ACS and normal oxygen saturation in any setting (prehospital, emergency, or in-hospital)

 (P), does does withholding oxygen


 (I), compared with compared with routine supplementary oxygen

 (C), change death, infarct size, chest pain resolution, ECG resolution (O)?
Consensus on Science:
For the critical outcome of mortality, we have identified very-low-quality evidence (downgraded for indirectness, heterogeneity, and bias) from 4 RCTs(Rawles 1976, 1121-1123; Ukholkina 2005, 59; Ranchord 2012, 168-175; Stub 2015, 2143-2150) enrolling 871 patients showing no benefit (OR, 0.91; 95% CI, 0.25–3.34) when oxygen is withheld compared with routine supplementary oxygen administration (Figure 5). For the important outcome of infarct size, we have identified very-low-quality evidence (downgraded for bias, inconsistency, indirectness, and imprecision) from 3 RCTs(Rawles 1976, 1121-1123; Ranchord 2012, 168-175; Stub 2015, 2143-2150) enrolling 713 patients showing a small reduction in infarct size when oxygen is withheld compared with routine supplementary oxygen administration. Data from a fourth RCT suggesting increased infarct size when oxygen is withheld could not be used because of incomplete reporting and unvalidated methods.(Ukholkina 2005, 59) The trial data generated for infarct size are too heterogeneous to enable combined assessment.For the important outcome of chest pain resolution, we have identified very-low-quality evidence (downgraded for bias, inconsistency, indirectness, and imprecision) from 2 RCTs(Rawles 1976, 1121-1123; Wilson 1997, 657-661) enrolling 199 patients showing no difference when oxygen is withheld compared with routine supplementary oxygen administration.For the important outcome of ECG resolution, no evidence has been identified in RCTs.
Treatment Recommendation:
We suggest withholding oxygen in comparison with routine oxygen supplementation in normoxic patients* with ACS† (weak recommendation, very-low-quality evidence). *Two later studies of SpO2 greater than 93% or 93% to 96%.†Patients with AMI, excluded previous myocardial infarction, severe chronic obstructive pulmonary disease, respiratory failure, cardiogenic shock, central cyanosis, SpO2 less than 85%, dyspnea from any other cause.Values, Preferences, and Task Force InsightsIn making this recommendation, we place a higher value on avoiding possible harm when the evidence available suggests no mortality benefit and possible harm in providing routine oxygen supplementation. We acknowledge the pending results of 2 additional trials addressing this topic. No data were identified for routine administration of oxygen with lower concentrations than those used in the reviewed trials (4–8 L/min via mask or nasal prongs). Oxygen saturation readings from pulse oximetry should be interpreted with caution, and every effort should be made to recognize and correct patient- or equipment-related factors that might lead to inaccurate results.
CoSTR Attachments:
887 Bias O2 in ACS_n.xlsx    
887 FP Hospital mortality –random effects model_n.docx    
887 FP Pain relief MI size_n.docx    
887 SOF O2 ACS 150203_n.docx    
Copy of 887 Data Collection O2 in ACS_n.xls    

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