Published: 13 December 2017

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NSAIDs and Heart Disease

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Prescriber Update 38(4): 61
December 2017

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat pain and inflammation. These medicines are available on prescription and over the counter.

Safety Concern

Research has shown that all NSAIDs are associated with an increased risk of serious cardiac events. The effect of dose and treatment duration have been extensively investigated. Currently, the frequency of these events appears to be similar for all NSAIDs.

Recent Meta-analysis

In a meta-analysis published in 2017, the risk of acute myocardial infarction in patients taking NSAIDs was analysed using real world data¹. The analysis investigated the effects of ibuprofen, diclofenac, naproxen, celecoxib and rofecoxib. The risk of acute myocardial infarction in NSAID users was compared with non-users.

The analysis indicated that all NSAIDs were associated with an increased risk of acute myocardial infarction. The risk of myocardial infarction with celecoxib was comparable to that of traditional NSAIDs. The authors noted that the risk increased from the first week of use.

What this study tells us

The recent meta-analysis indicates that there is no difference between NSAIDs or celecoxib regarding the risk of myocardial infarction.

Consistent with previous analyses, high doses were associated with greater risk of cardiac events. For example, no risk of cardiac events was found with low dose (over the counter dose) of ibuprofen².

Although there is small increased risk of cardiac events associated with NSAID use, the benefit outweighs the risk of harm when used according to the instructions in the data sheet.

The MARC has previously recommended that the lowest possible dose of NSAID for the shortest period of time should be used and long-term treatment with NSAIDs should be reviewed regularly ³.

Individual risk factors should be taken into account before prescribing a NSAID and the patient should be advised of the risk of harm.

Cases in New Zealand

Between January 2005 and 30 September 2017, the Centre for Adverse Reactions Monitoring (CARM) received 11 reports of myocardial infarction or cardiac arrest.

Table 1: Cases of myocardial infarction and cardiac arrest reported to CARM January 2005 to September 2017

Medicine	Myocardial infarction	Number of cardiac arrests
Celecoxib	0	0
Diclofenac	3	2
Ibuprofen	3	1
Naproxen	1	1

References

1. Bally M, Dendukuri N, Rich B, et al. 2017. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ 357: j1909.
2. 2015. Ibuprofen and Cardiovascular Risk. Prescriber Update 36(3): 42. URL: www.medsafe.govt.nz/profs/PUArticles/Sep2015/Ibuprofen&Cardiovascular.htm (accessed 17 November 2017).
3. 2008. Non-Selective NSAIDS - Cardiovascular, Skin and Gastrointestinal Risks. Prescriber Update 29(1): 15–16. URL: www.medsafe.govt.nz/profs/PUArticles/NSAIDSRisks.htm (accessed 17 November 2017).