A 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 While NSAIDs have been associated with adverse coronary events, the most well-known being Vioxx which was withdrawn from the market in 2004 (thank you Dr.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?