Nsaids May Raise Heart Attack Risk In First Week Of Use
When headache or back pain strikes, many of us turn to ibuprofen for some quick relief. A new study, however, finds that using this and other classes of nonsteroidal anti-inflammatory drugs for as little as 1 week may increase the risk of heart attack.
Study leader Michèle Bally, of the University of Montreal Hospital Research Center in Canada, and colleagues recently reported their findings in The BMJ.
According to the Centers for Disease Control and Prevention , every year, around 735,000 people in the United States have a heart attack, otherwise known as myocardial infarction.
A number of studies have suggested that the use of certain nonsteroidal anti-inflammatory drugs may increase the risk of heart attack.
So strong is this evidence that, in 2015, the U.S. Food and Drug Administration strengthened their warning about the risk of heart attack with the use of over-the-counter and prescription NSAIDs.
However, Bally and colleagues note that previous studies looking at the risk of heart attack with NSAID use have been subject to various limitations, such as small sample sizes and lack of comparisons with a placebo.
As a result, the team says that these studies have failed to generate a solid understanding of which NSAID doses pose the greatest risk or how the length of use may impact heart attack risk.
What Are The Alternatives To Nsaids
In cases where the risk of taking an NSAID outweighs the benefits, there are alternatives we can try to manage your pain, including:
- Non-narcotic non-steroidal pain medications, such as acetaminophen or tramadol
- Topical medications rubbed into the skin to relieve muscle or joint pain
- Exercise or physical therapy
- Cognitive behavioral therapy
If you are concerned about NSAIDs and your heart health, request an appointment online or call .
What Are The Heart Risks Of Nsaids
Heart concerns over NSAID use took off in the early 2000s. Studies showed an increased risk of heart problems in patients who took a class of NSAIDs that included Celebrex and Vioxx. More recently, weve discovered nearly all NSAIDs pose some risk to cardiovascular health especially in those who use them heavily.Many people take aspirin to help prevent heart attacks and strokes. What makes aspirin different from other NSAIDs? While aspirin prevents blood platelets from clumping together to form dangerous clots in blood vessels, non-aspirin NSAIDs can increase blood clot formation, which can lead to heart attacks and strokes.Based on these studies, the FDA now requires prescription non-aspirin NSAID labels to state:
- The risk of heart attack or stroke starts as early as the first week of NSAID use and increases with prolonged use.
- Heart risk is greater at higher doses.
- While all patients are at risk despite their health history, those with heart disease or risk factors are at higher risk.
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Absolute Versus Relative Risk: Beyond The Headlines
While the risks found in this analysis appear to be real, its essential to recognize that these are relative risk increases, not absolute risk increases. If your underlying risk is low, then the incremental risk is low. This paper does not report absolute risks. The authors suggest using a risk calculator like the Framingham Risk Score to estimate the 10 year risk of coronary heart disease, and use that finding as a guide to place this research in context. They note:
Without use of NSAIDs, one could expect that the number of cases of acute myocardial infarction will be fewer than 1 case per year per 100 persons in those at low risk , 1 to 2 cases per year per 100 persons in those at intermediate risk , and greater than 2 cases per year per 100 persons in those at high risk .
Assuming an increase in the relative risk of acute MI of 20 to 50% across NSAID doses and durations studied in the IPD meta-analysis, the number of excess acute myocardial infarctions associated with use of common NSAIDs might range from fewer to 0.2 to 0.5 case per year per 100 persons in those at low coronary risk or < 0.2-0.5% annually up to 0.4 to 1 or more cases per year per 100 persons in those at high coronary risk or > 0.4 to 1% annually . Hence the absolute percentage increase of excess MIs due to NSAID exposure is likely to range from 0.2% to 1% annually.
Emphasis added.
How Do Nsaids Cause Heart Attacks
Aspirin prevents platelets from clumping together, which prevents the formation of dangerous clots that can block a vessel and cause a heart attack or stroke. The non-aspirin NSAIDs work on that enzyme, too, but also affect another enzyme that promotes clotting. That can lead to heart attacks and strokes.
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Paracetamol And Cv/cerebrovascular Risk
Despite some previous data suggesting a possible association of paracetamol with CV risk due to its effect on blood pressure, a retrospective analysis by Fulton and colleagues confirmed the safety of acetaminophen after collecting data from the UK Clinical Research Practice Datalink. No relationship could be found between verified acetaminophen prescription data and risk of MI or stroke in patients with hypertension over a 10-year period. Among the 10,878 acetaminophen-exposed individuals aged at least 65 years, there was no relationship between risk of MI, stroke or any CV event and acetaminophen exposure compared with the 13,618 individuals not exposed. The results when men and women were analyzed separately were similar and even high-frequency users were not at increased risk. The safety of paracetamol was also confirmed in another cohort study of 36,754 patients diagnosed with OA and with a first-time prescription of NSAIDs between 2002 and 2012. CV and cerebrovascular events were identified in 2182 cases: no association was found between the use of acetaminophen containing medication and the occurrence of acute CV or cerebrovascular events. These findings support the choice of acetaminophen therapy for OA-related pain, especially in those patients presenting with cerebrovascular and CV morbidities or related risk factors.
Treating Pain: Between A Rock And A Hard Place
Its important to remember that this new paper doesnt change what weve known for some time: If your baseline risk of a heart attack or stroke is low, then NSAIDs raise your risk only slightly. However, given the fact NSAIDs are taken so casually, the apparent rapid escalation of risk should concern anyone with a modest- to high-risk of a heart attack who might not normally have worried about several days of high-dose NSAID use . What this analysis shows is that theres an apparent rapid increase in risk.
Overall, these findings reinforce the fact that we lack safe and effective treatment options for chronic pain control. With the opioid epidemic killing thousands across North America, theres more awareness than ever of the risks of using narcotic analgesics for acute or chronic pain. However, many patients with chronic pain may be older, or have risk factors for cardiovascular disease, and shouldnt be on NSAIDs. Given the modest and even questionable effectiveness of acetaminophen for many types of chronic pain, there are few effective medical options remaining. Ive written before about topical NSAIDs which appear to lack the toxicity of oral products. They may be a reasonable alternative for those that want to minimize their risk, or are seeking treatment alternatives.
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Possible Mechanisms For The Increased Risk Of Thrombotic Events
The first theory trying to explain the risk of thrombotic events of selective COX-2 inhibitors was based on the assumption that COX-2 in the vessel wall was an important source of prostacyclin, whereas COX-1 was responsible for the production of thromboxane in platelets. Selective COX-2 inhibition would in this situation decrease the production of PGI-2, which is a vasodilating and antithrombotic substance, without inhibiting the vasoconstricting and thrombogenic TXA-2. The resulting imbalance between pro-thrombotic and antithrombotic factors could lead to thrombosis .
On the other hand, the greater risk of thrombotic events with highly selective COX-2 inhibitors when compared with non-selective NSAIDs apparently cannot be explained only by the concomitant inhibition of platelet function with the non-selective agents. For a clinically significant suppression of platelet aggregation, greater than 95% inhibition of COX-1 is needed. This happens only with aspirin, and in certain situations with high dose naproxen .
Despite of the above described theories, the exact mechanisms responsible for the high variability of the thrombotic risk with various NSAIDs remain unknown. To further elucidate the reason behind the differences in the observed degree of CV risk between various NSAIDs, more focus should be placed on studies scrutinizing their exact pharmacokinetic and pharmacodynamic properties .
When Do Nsaids Become Dangerous
Just as with any medication, the use of NSAIDs comes with its benefits and risks. We will work with you to ensure that if NSAIDs are necessary, their benefits far outweigh the increased risk of heart attack or stroke. Generally speaking, however if we do have a different, safe, but similarly effective option, we will pursue it. Otherwise, the following are some ways to reduce your risk of heart attack or stroke when taking NSAIDs
- Take the lowest possible dose to get relief
- Take it for the shortest period of time to get relief
- Do not drink while taking NSAIDs
- Try other pain relievers such as acetaminophen/Tylenol instead
- Take NSAIDs only on the orders of your cardiologist.
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The Cyclooxygenase Enzyme And Its Physiologic Roles
NSAIDs are cyclooxygenase inhibitors. COX is an enzyme, which produces prostaglandin H2 from arachidonic acid. PGH-2 is a metabolite converted into prostanoids by tissue specific enzymes.
Two basic isoforms of cyclooxygenase are known to date: COX-1 and COX-2. Initially, COX-1 was thought to be the constitutive form of the enzyme playing an important role in physiologic functions of the human body. At the same time, COX-2 was considered strictly inducible and thought to be responsible for inflammation and pain under pathologic circumstances. Recently, this theory was proven to be too simplistic. It is now known that COX-2 is permanently present in several tissues of the human body and plays an important role in multiple physiologic processes.
With regards to the most common serious ADRs of NSAIDs, it is important to understand the role of COX-1 in the formation of protective;prostaglandin E2 and prostacyclin . Both of these play a protective role in the gastric mucosa. In thrombocytes, COX-1 forms thromboxane A2 , which is a prostanoid antagonizing the anti-thrombotic and vasodilating effect of PGI-2 formed in the arteries by both COX isoforms. Within the kidney, PGE-2 formed by COX-1 plays a decisive role in the regulation of glomerular filtration, while PGI-2 produced by COX-2 affects renin secretion. Finally, products of both COX isoforms play a role in the kidney regulating excretion of sodium and water.
Nsaids And Cardiovascular Risk Explained
- Date:
- Perelman School of Medicine at the University of Pennsylvania
- Summary:
- After nearly 13 years of study and intense debate, a pair of new articles have confirmed exactly how a once-popular class of anti-inflammatory drugs leads to cardiovascular risk for people taking it.
After nearly 13 years of study and intense debate, a pair of new papers from the Perelman School of Medicine, at the University of Pennsylvania have confirmed exactly how a once-popular class of anti-inflammatory drugs leads to cardiovascular risk for people taking it.
It has been almost eight years since Vioxx® was withdrawn by Merck from the market, provoking an intense controversy about the role inhibitors of the enzyme COX-2 play in causing heart attacks and strokes. Since then, other drugs in the class from Pfizer, Novartis, and Merck have been withdrawn ; have failed to be approved ; or have been retained on the market in the US with a “black box” warning on the label .
More than 10 years later, it is now clear what the COX inhibitors do in the body. Eight placebo-controlled, randomized trials, performed to find new uses of these drugs, showed that they posed a cardiovascular hazard, similar in magnitude to that resulting from being a smoker or a diabetic, notes FitzGerald. “Despite this, controversy has continued about how all this came about, until now.”
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Nsaids: How Dangerous Are They For Your Heart
- By Christian Ruff, MD, MPH, Contributor
Nonsteroidal anti-inflammatory drugs, commonly referred to as NSAIDs, are one of the most common medications used to treat pain and inflammation. Ibuprofen, naproxen, indomethacin, and other NSAIDs are effective across a variety of common conditions, from acute musculoskeletal pain to chronic arthritis. They work by blocking specific proteins, called COX enzymes. This results in the reduction of prostaglandins, which play a key role in pain and inflammation. There are two types of NSAIDs: nonselective NSAIDs and COX-2 selective NSAIDs .
There is a growing body of evidence that NSAIDs may increase the risk of harmful cardiovascular events including heart attack, stroke, heart failure, and atrial fibrillation. Given the widespread use of NSAIDs, these findings have generated significant concern among patients and healthcare providers. I am frequently asked by patients: is it safe to continue to take NSAIDs?
Nsaids And Their Effect On Blood Pressure
As reported by Lapi and colleagues, a possible explanation for the increased risk of cerebrovascular events related to the use of NSAIDs could be their effect on blood pressure. Even the mechanism by which NSAIDs increase blood pressure is still not clear. The blockage of the COX enzyme and the relative inhibition of prostaglandin synthesis, which induces vasoconstriction, as well as volume expansion, due to impaired sodium excretion, all seem to play an important role. NSAIDs can also potentially decrease the effectiveness of the commonly used antihypertensive drugs.
In contrast to the evidence for an NSAID hypertensive effect, in a study among patients with hypertension and coronary disease, it was found that chronic NSAID use for nearly 3 years was actually associated with slightly lower blood pressure levels compared with nonuse. Thus any hypertension-mediated effect may be specific to the duration of NSAID use and warrants further clinical investigation.
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Beyond The Ischemic Cardiopathy: The Cerebrovascular Risk
The studies related to the prothrombotic effect of coxibs or nonselective NSAIDs are mainly focused on ischemic cardiopathy, while the evidence concerning the risk of ischemic stroke/transient ischemic attack and hemorrhagic stroke is still debated. The paucity of stroke events in the overall population, when compared with CV events, plays a central role in the lack of clarity about possible relationship between cerebrovascular risk and NSAID administration. Much of the data are therefore derived from observational studies and meta-analyses rather than randomized controlled trials.
In a study by Lapi and colleagues, a cohort of 29,722 patients with a diagnosis of osteoarthritis treated with NSAIDs were evaluated to determine whether the use of NSAIDs is associated with an increased risk of cerebrovascular events. In a study period of 10 years, the authors identified 1566 cases of cerebrovascular events without any correlation between current use of NSAIDs compared with past use. Among individual NSAIDs, diclofenac and ketoprofen were significantly associated with an increased rate of cerebrovascular events. The most frequent event was hemorrhagic stroke following the use of ketoprofen.
Celecoxib: Not So Hard On The Heart
The recent findings of a huge study may erase some concerns about a pain reliever that has long been saddled with a worrisome reputation: celecoxib . While all nonsteroidal anti-inflammatory drugs carry a warning that users have an increased risk for heart attacks and strokes, celecoxib is closely linked to two similar drugs that were taken off the market due to concerns about their cardiovascular safety. However, the new research suggests that celecoxib may not be more dangerous than other NSAIDs, and might even be safer in some important ways.
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Fda Strengthens Warning On Nsaids And Heart Risk
July 10, 2015 — Popular painkillers like ibuprofen and naproxen have carried warnings for years about potential risks of heart attacks and strokes. This week, the FDA decided to strengthen those warnings on the medications, known as nonsteroidal anti-inflammatory drugs, or NSAIDs.
The warning includes both prescription and over-the-counter versions of drugs. It emphasizes that the risk applies to even short-term use of medications like Advil, Aleve, and Motrin. And itâs true for people with or without heart disease.
WebMD turned to three experts to sort out the issues.
Why is the FDA requiring stronger warning labels?
After looking at new safety information on both forms of the drugs, the FDA determined that the risks are greater than originally believed. The risk of heart attack and stroke can happen even in the first few weeks of using the drugs. And that risk is greater the higher the dose. These worse odds apply to people with or without a history of heart disease, the FDA says.
“They are not ruling out risk on a short-term basis,” says Bill McCarberg, MD, a San Diego family physician who has published extensively on NSAIDs. The new warning, he says, “lets even occasional users know they are taking a risk.”
While some NSAIDs may be less risky, the agency says the information it has now is not enough to rate individual drugs by risk level.
How do NSAIDs boost the risk of heart attacks and strokes?
Is there any way to pick the ”safest” NSAID?
Whats The Link Between Nsaids And Heart Attacks
The risk of NSAIDs causing heart attacks, strokes, and other cardiovascular events is related to how strongly the NSAID blocks COX-2. In general, the more a medication focuses on stopping COX-2, the higher the risk is for serious heart-related problems.
Over the past 20 years, multiple studies have looked at NSAIDs and their effect on the heart. Its important to know which NSAIDs carry the highest risk for heart attacks and whether or not the dose you take matters. Well answer these questions, and more, below.
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