Patient Alert: Don’t Take NSAIDs After a Heart Attack

NSAID tabletsA study from Denmark of almost 100,000 patients over a 12-year period has concluded that:

The use of NSAIDs is associated with persistently increased coronary risk regardless of time elapsed after first-time MI. We advise long-term caution in using NSAIDs for patients after MI.

The study, published online before print in Circulation is titled, “Long-Term Cardiovascular Risk of NSAID Use According to Time Passed After First-Time Myocardial Infarction: A Nationwide Cohort Study.”  The researchers looked at the nationwide registries of hospitalization and drug dispensing from pharmacies in Denmark for the years 1997-2009 and calculated the incidence of death and heart attack associated with NSAID (Non-Steroidal Anti-Inflammatory Drug) use up to five years after a heart attack (in one-year increments).

The NSAIDs specifically looked at were celecoxib (Celebrex), rofecoxib (Vioxx), ibuprofen (Motrin, Advil), diclofenac, and naproxen. While NSAIDs have been associated with adverse coronary events, the most well-known being Vioxx which was withdrawn from the market in 2004 (thank you Dr. Eric Topol), this study demonstrates that even drugs that are sold over-the-counter in the U.S., such as ibuprofen and naproxen, can have negative effects for patients who have experienced a heart attack even more than five years after that event.

Diclofenac had the highest risk of all NSAIDs, even higher than Vioxx, and a large concern is that diclofenac is sold over-the counter in many countries under a number of brand names. Naproxen, on the other hand, was the least risky NSAID and the authors stated that it may be an alternative in cases where an NSAID pain reliever is critical to the patient’s well-being.

Aspirin, the most widely-used pain reliever which technically is an NSAID, was not included in the study because, as Dr. Anne-Marie Schjerning Olsen, lead author of the study, told Angioplasty.Org:

“In Denmark aspirin is available over the counter, which explains why the fraction of patients who fill prescriptions for aspirin in our study is relatively low. We therefore didn’t have the opportunity to analyze the effect of aspirin. However previous studies have shown that low-doses of aspirin are cardio protective; however the effect of high-doses is not known.

In fact, it is known that certain NSAIDs counteract the cardio protective properties of aspirin.

A major concern of the authors, however, is that even though the cardiovascular risk for taking NSAIDs after a myocardial infarction is relatively high and well-known, the use of these drugs over the course of the study did not decline, even though such risks were publicized through headlines such as those associated with the Vioxx recall. For example, 44% of the 99,187 patients looked at in this study were prescribed NSAIDs by their physicians. The authors furthermore question whether the over-the-counter status of NSAIDs such as ibuprofen and diclofenac should be reconsidered, in light of this data.

At the least it is clear that patients who are recovering from a heart attack need to be informed by their healthcare providers that any NSAID can increase the risk of a repeat MI or death, and that there is no safe window outside of which it will be okay in the future.

But will studies like this one change medical practice?


Filed under Heart Attack, Patient Alert, Patient Empowerment, Patients, Risk Factors

15 Responses to Patient Alert: Don’t Take NSAIDs After a Heart Attack

  1. bharat

    there is no suggestion what kind of pain killer is safer and can be taken with out fear of any adverse reaction ,if needed.

    • The study showed that Naproxen had the least risk, among the NSAIDs. There is also acetaminophen (Tylenol, etc.). And most likely you are already on aspirin. Depending on the type of pain, one may be more targeted than another. As with all posts asking for medical advice, we would suggest discussing this with your cardiologist. And thanks for posting.

  2. Deborah Palacpac

    Then what are patients suppose to take for arthritic pain as we age? If I can’t take nsaids what am I suppose to take. Tylenol is not effective for arthritis pain. Don’t tell me to consult my doctor because he said Tylenol or Excedrin . Both are ineffective for pain control. My joints hurt . I’m a nurse for 35 years . I have walked many long hallways. Publish a report that helps me. Or make narcotics over the counter so I can get pain relief.

    • Deborah – You are right. Excedrin is also Tylenol plus aspirin (which you are probably taking already if you have had a heart procedure). Of all the NSAIDS, naproxen has been shown as having the least effect on increasing risk of a cardiac event. I assume you’ve had some type of cardiac event already?? Narcotics are not a good long-term solution, because of their addictive nature.

  3. Asher Kelman

    For long term pain relief of the post MI patient with severe arthritic pain, long term narcotic dependence should not be any concern. After all, we are not in war torn countries where drug supply can be haphazard. I do not see any issue with prescribing what is needed to deal with pain that tortures a patient’s every moment!

    We don’t want folk undergoing hip surgery or other trauma to end up neglected and not tapered off and transferred to non-addictive drugs.

    The big problem of long term use of narcotics is ghastly constipation, for which so many remedies are offered. Still that alone gives me pause!

    Radiation Oncologist with decades of experience in pain control.

    Of course, this comment does not merit being used in place of a visit to a physician expert in pain control.

  4. Charles A Griffis

    Hi Dr. Kelman.
    As a Certified Registered Nurse Anesthetist with a PhD and research in pain pathophysiology, I would like to share some relatively new information. Both our and several other laboratories have discovered that chronic opioid therapy causes an increase in inflammation in the spinal cord pain neurons through a complex pathway involving glial cell responses to opioids via the mu opioid receptor. Most chronic pain anesthesiologists would agree that opioid therapy is not the answer for chronic pain, as eventually, this long-term effect begins to worsen pain as larger doses of opioids are required due to the development of tolerance. Certainly, we would agree that narcotics should be used for short term, acute pain. But then as soon as possible, the patient should graduate to non-opioids. Thus, acetaminophen and cautious use of naproxen with the guidance of the cardiologist or pain specialist may be the best solution for cardiac patients with intractable arthritis pain, not to mention multimodal approaches like pain blocks, rehab exercise, acupuncture, and guided meditation. Good luck everybody! It’s such a hard problem!!

  5. Patrick Delaney

    Hi. Just had a knee replacement 3 months ago and my knee is still swollen and my orthopedic suggested Advil, but my cardiologist says it is not the way to go. I was taking 2 aspirins 81 mg each day. I am down to 1. If i were to stop the aspirin and take Advil for a short period to reduce the swelling , would that have an effect . By the way, I had a stent put in my lad ( left arteriel descending ) in 2004. Thank you in advance for your help

    • Patrick – There have been studies linking NSAIDs like ibuprofen (Advil, Motrin, etc.) to some adverse cardiac issues, so that would be why your cardiologist said not to take Advil. Did he/she give you an alternative? Perhaps have the cardiologist and orthopedist discuss your issues with each other. There are topical creams that might reduce swelling in your knee area, and that would not require you to be taking a systemic NSAID. Or perhaps your orthopedist can suggest other non-pharmaceutical therapies. Good luck.

  6. Richard Baldwin

    Sounds like it’s damned if I do and damned if I don’t , where is the suggestion of cannibid oil

    • Richard – I believe you are referring to cannabidiol, or CBD. Have you used this for pain? You’ll note that this blog was posted on 2012, before CBD was legalized anywhere in the U.S. It’s still a grey area in many states.

  7. Richard Baldwin

    I assume there is no real answer to chronic inflammation that won’t clog stents or just kill a person outright

  8. Richard Baldwin

    Mine only lasted 3 years , I was taking naproxen , one pill a day , that isn’t very long term , cbd just might be the answer

    • Richard – there are a number of reasons why stents close up over time (called “restenosis”). It’s become much less of a problem with the newer generations of stents, but not if it happens to be the stent in you! Sorry to hear yours closed up after three years. Curious how that was treated? Was a balloon put in to re-expand it? Was another stent slipped inside? As for Naproxen, the warnings about NSAIDs are about the findings that they may cause an increased incidence of heart attack. They don’t, as far as we know, have a role in increasing restenosis.

  9. Richard Baldwin

    A stent was inserted within
    I was told by a heart doctor that it does help in clogging stents

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