Do NSAIDs Increase the Risk of Heart Attacks?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed class of medicines used around the world, and are widely used by individuals with arthritis, and back pain.  Starting with the development of aspirin from the active agent found in willow bark (salicylic acid) NSAIDs have offered humans the ability to decrease pain, fever, and inflammation.  Along with these benefits come risks associated with gastrointestinal bleeding, fluid retention and high blood pressure (hypertension). Sustained hypertension is associated with damage to the cardiovascular system including hardening of arteries and resulting heart attacks.  In the usual circumstance, hypertension needs to be sustained for an extended period of time for damage to the coronary arteries to occur.

A new study concerning NSAIDs proposes that the risk for a heart attack may occur soon after starting any one of a number of these drugs. Bally and coauthors recently report that the risk for a heart attack is increased within the first week of starting a nonsteroidal drug.  They reviewed over 82 studies identifying 446,763 individuals experiencing a total of 61,460 heart attacks.  They divided groups into those who had heart attacks within a week, a month, or more than a month.  The NSAIDs reviewed were ibuprofen, naproxen, diclofenac, and rofecoxib. No difference was found among these various drugs with regard to risk of heart attack.  No data was available as to the exposure to low or high doses of drug.  Individuals who were taking medicine for longer periods of time did not seem to experience an increasing risk.

A number of limitations were mentioned by the authors in the paper and by reviewers subsequent to its publication.  One major inconsistency that I would point out is the absence of aspirin from the analysis.  Aspirin is a NSAID.  It is used for secondary prevention of heart attacks for those who have already experienced an event.  If all NSAIDs are implicated by this report, cardiologists would be wrong in all of their research that has shown the benefits of aspirin in this circumstance.

In a recent post, I reviewed the findings of the PRECISION trial.  In that report, celecoxib, ibuprofen, and naproxen were studied to determine the predisposition of study subjects to the development of cardiovascular events.  The study was extended over fifteen years because the frequency of events was so low with these NSAIDS that were used for longer than one week.

The decision to use a NSAID is a serious one that should only be made after a discussion with your physician.  A number of factors of a single individual (weight, blood pressure, being sedentary) all play a role in estimating risk.  At the same time, the benefits of therapy need to be considered in determining the use of a NSAID.

Reference:

  1. Bally M, Dendukuri N, Rich B et al: Risk of acute myocardial infarction with NSAIDs in real world use: baysesian meta-analysis of individual patient data. BMJ 2017;357:1909
  2. Nissen SE, Yeomans ND, Solomon DH et al. Cardiovascular safety of Celecoxib, Naproxen, or Ibuprofen for arthritis. NEJM 2016;375:2519-29

David Borenstein, M.D.

Executive editor TheSpineCommunity