Pain relievers: Bad for your heart?

People with heart disease should avoid prolonged use of certain anti-inflammatory drugs. Naproxen (Aleve) is safest.The “stomach friendly” prescription pain relievers Vioxx (rofecoxib) and Bextra (valdecoxib) were removed from the market when evidence emerged that they raised the risk of heart attacks. But Vioxx and Bextra left behind a couple of over-the-counter cousins: ibuprofen (Advil, Motrin) and naproxen (Aleve). The ways these drugs work are quite different, but they are all members of the
family called nonsteroidal anti-inflammatory drugs (NSAIDs).

NSAIDs reduce pain, inflammation, and fever. To call them widely used is an understatement. Up to 40% of people 65 and older take an NSAID daily. But concern among cardiologists has grown with evidence that NSAIDs raise the risk of a second heart attack or death. So if you have heart disease, how should you manage pain?

New evidence of NSAID risk

NSAIDs are safe when taken at low to moderate doses and for limited periods—unless you have kidney disease or a history of gastrointestinal bleeding or ulcers. However, NSAIDs may be risky for people who have heart disease or are likely to develop it.

The latest study to show this appeared October 16, 2012, in Circulation. Scientists analyzed health records of nearly 100,000 Danes who had already had one heart attack. Those who took an NSAID of any kind in the next five years were at 41% higher risk of having a second heart attack and 63% increased risk of dying from any cause, compared with those who did not take NSAIDs.


Risky pain relief?

The study does not absolutely prove that taking NSAIDs causes people to have heart attacks. But added to previous findings, it has raised concerns among cardiologists. “A picture is emerging that people at high risk of a heart attack are at increased risk if they take any kind of NSAIDs,” says Dr. Paul L. Huang,
a professor of medicine at Harvard Medical School and director of the Cardiac Metabolic Syndrome Program at Massachusetts General Hospital. “The take-home message of the most recent study is consistent with other reports.”

In 2007, the American Heart Association released relatively conservative guidelines on NSAIDs. The guidelines cautioned doctors against using NSAIDs or any other medications for musculoskeletal pain until first trying heat and cold, physical therapy, exercise, and weight loss. Failing that, the AHA advised, use non-NSAID pain relievers, and then NSAIDs as the last choice.

Why NSAIDs should raise heart risk is not entirely clear. Many people with heart disease are taking aspirin, and NSAIDs may interfere with aspirin’s protective effect. Also, all NSAIDs have a tendency to cause arteries of the heart to go into spasm and form blood clots.


What should you do?

Dr. Huang now believes that physicians should be cautious with NSAIDs. “We should be encouraging people not to take them, even over-the-counter types, if they’ve had a heart attack.”

People at greatest risk would be those using NSAIDs at maximum daily doses for extended periods of time. “Take as little as you need,” advises Dr. William Kormos, editor in chief of Harvard Men’s Health Watch and a primary care physician at Harvard-affiliated Massachusetts General Hospital. “Limiting NSAIDs to short term use, such as two weeks of ibuprofen for a shoulder strain, is a safer option for patients at risk for heart disease.”

The bottom line: The potential risk of NSAIDs is highest in people with heart disease or with major risk factors for it. Naproxen is the least risky choice if you need to use an NSAID. If in doubt, ask your doctor for specific advice.

How to reduce the heart risk from NSAIDs

  • Use NSAID alternatives: Take acetaminophen (Tylenol, other brands) instead of an NSAID, unless you have a liver problem or some other condition that would limit your use of this drug. (If you are not sure how much is safe, ask your doctor.) Acetaminophen treats pain and fever, but not inflammation. For people with osteoarthritis, reducing inflammation is usually important, so this option won’t work for everyone.
  • Use the safest NSAID: Some NSAIDs may be less risky than others. The Danish study links the prescription NSAID diclofenac (Voltaren) to the highest risk for second heart attack and naproxen (Aleve, other brands) with the lowest risk. “For people who can’t take acetaminophen because of liver disease or other reasons, naproxen would be a reasonable alternative,” Dr. Huang says.
  • Take your aspirin first: Aspirin prevents clotting that can lead to a heart attack. Some studies suggest NSAIDs may interfere with aspirin’s protective effect. So if you have heart disease and must use NSAIDs, take the aspirin first, wait an hour, and then take your required dose of the NSAID drug, Dr. Huang suggests.
  • Use only what you need: Taking NSAIDs for short periods from time to time—for example, to tackle an ordinary tension headache—poses less risk than routine, long-term use at high doses.



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