Morphine, Oxygen, Nitrates, and Mortality Reducing Pharmacological Treatment for Acute Coronary Syndrome: An Evidence-based Review

Since it was first reported in 1912, acute coronary syndrome (ACS) has become the leading cause of death in the Western world. Several improvements that have been made over the years in the pharmacological treatment of ACS have reduced the relative risk of death due to myocardial infarction from 35-45% previously to approximately 3.5% at present. Universities, websites, and educational videos commonly use a mnemonic for morphine, oxygen, nitrates, and aspirin (MONA) to refer to the adjuvant treatment used for the management of ACS. We review the scientific data pertaining to treatment strategies for the management of ACS and discuss whether MONA remains relevant in the present scenario. While using morphine and oxygen is associated with risks such as higher mortality and increase in the size of the infarct, respectively, several available drugs such as fibrinolytics, anticoagulants, beta-blockers, renin-angiotensin-aldosterone system inhibitors, P2Y12 inhibitors, and statins are known to be useful to treat ACS. MONA should be viewed as an obsolete teaching and learning aid, and therefore we recommend that its use be discontinued for the management of ACS.