NSAIDs: How dangerous are they for your heart?

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 (these are sometimes referred to as “coxibs”).

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 cardiovascular disease: Minimizing the risks

There are several factors to consider when evaluating the potential risk of NSAID therapy. The first is the duration of treatment. The risk of having a heart attack or stroke is extremely small over a short course of therapy (less than one month), such as would be the case in treating acute pain from a musculoskeletal injury like tendonitis. Another important consideration is dose and frequency. The risk tends to increase with higher doses and increased frequency. The third factor is whether the person has existing cardiovascular disease. In people without known cardiovascular disease, the absolute increase in risk is incredibly small (one to two excess cardiovascular events for every 1,000 people who take NSAIDs).

My general principles for NSAID use are:

  1. In all patients, I recommend the lowest effective NSAID dose for the shortest duration of time to limit potential side effects.
  2. In people without known cardiovascular disease, the increase in risk is so minimal that it rarely influences my decision about whether to use NSAIDs.
  3. In patients with known cardiovascular disease, I might advise an alternative treatment. Many patients with pre-existing heart disease can be safely treated with short courses of NSAIDs. However, the choice of specific NSAID and dose is more important in these patients. I generally recommend the nonselective NSAID naproxen or the COX-2 selective NSAID celecoxib, as studies have demonstrated that these two drugs may have the best safety profile in higher-risk patients.

In summary, although all NSAIDs are associated with an increased cardiovascular risk, the magnitude of the increased risk is minimal for most people without cardiovascular disease taking them for short periods of time. For patients who have heart disease or who require long-term treatment with high doses of NSAIDs, the increased risk is more of a concern. If you fall into this category, discuss your options with your healthcare provider to determine whether an alternative therapy is possible, or to help select the safest NSAID option for you.

Related Information: Harvard Heart Letter

Comments:

  1. Raj

    I was diagnosed with Ankylosing Spondylitis some 20 years ago. At one point, my Rheumatologist suggested that I try a new type of medication that was becoming available – called TNF alpha blockers. Not wanting to be a guinea pig, I turned that down and sure enough, a few years ago, I read that TNF alpha blockers have been associated with increased risk of cancer.
    My doctor suggested for me to atleast be on a regular dosage of Naproxen. When I told him that I take it only when I had pain, he thought that was silly and couldnt understand why I wouldnt take this safe medication. Now we hear about all these heart risks.

    Goes to show that we need to take all these expert opinions with a generous does of skepticism. Not that the individual doctors are wrong – but, the way western medicine is practiced it seems we develop these narrowly focused “solutions” without understanding the impact to the overall system of human body.

  2. Paul

    What would you recommend for chronic arthritis in knees?

    • Christian Ruff, MD, MPH

      For patients with no history of cardiovascular disease the choice of NSAIDs probably does not matter very much. For patients with a history of cardiovascular disease we generally recommend I generally recommend the naproxen or celecoxib,

  3. P Toro

    I’ve often heard that for an NSAID to provide effective therapy for an injury, it should be taken regularly, around the clock, for the recommended treatment period. Does that pose greater risk than taking it intermittently and, if so, how do we get around the need to take it regularly?

    • Christian Ruff, MD, MPH

      Yes.. that is correct. For acute injuries a short course of taking NSAIDs are regular dosing intervals are necessary to alleviate pain and inflammation. This generally poses minimal risk to most patients. Of more concern is when patients are taking large doses of NSAIDs regularly chronically (months to years).

  4. Christian T. Ruff, MD, MPH

    It is a great question. Aspirin is protective for the heart because it only effects platelet function. Basically preventing platelets from clumping together to form blood clots. While there is some overlap between the platelet effects of NSAIDs and aspirin, NSAIDs have have other effects on the lining of blood vessels which may actually predispose to clots to forming clots which can result in heart attacks or strokes. NSAIDs can also cause the kidneys to retain salt and water which may cause or exacerbate heart failure.

  5. Kim Motsinger

    You hear all this stuff about NSAIDs being bad for heart patients but nobody ever says what it does and why doesn’t aspirin pose the same threat what is the actual mechanical function that is harmful not enough to just tell me it’s bad

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