What happens when a patient with angina takes ibuprofen (Non-Steroidal Anti-Inflammatory Drug, NSAID)?

From the Guidelines

Patients with angina should avoid taking ibuprofen due to its potential to interfere with the antiplatelet effects of aspirin, which is commonly used to prevent cardiovascular events in these patients. According to a study published in Circulation in 2007 1, ibuprofen can prevent aspirin from irreversibly acetylating the platelet COX-1 enzyme, which may reduce the protective effect of aspirin on risk for atherothrombotic events.

When considering pain relief for patients with angina, it is essential to weigh the risks and benefits of different options. Some key points to consider include:

• NSAIDs, such as ibuprofen, can increase cardiovascular risks by reducing the effectiveness of medications like aspirin and ACE inhibitors, increasing blood pressure, causing fluid retention, and impairing kidney function 1.
• Acetaminophen (Tylenol) is typically a safer alternative for angina patients, as it does not have the same cardiovascular risks as NSAIDs.
• If pain control is inadequate with acetaminophen alone, patients should consult their cardiologist before using any NSAID, even for short-term use.
• The cardiologist may recommend alternative pain management strategies that won't interfere with angina treatment or increase cardiovascular risk, such as using the lowest effective dose of an NSAID for the shortest possible duration, or combining an NSAID with low-dose aspirin to assure effective platelet inhibition 1.

It is crucial to prioritize the patient's cardiovascular health and minimize the risk of adverse events. The most recent and highest quality study, published in 2007, suggests that patients taking immediate release low-dose aspirin and ibuprofen 400 mg should take the ibuprofen at least 30 minutes after aspirin ingestion, or at least 8 hours before aspirin ingestion to avoid any potential interaction 1. However, this may not be feasible or effective in all cases, and alternative pain management strategies should be considered.

From the FDA Drug Label

However, patients with known CV disease or risk factors had a higher absolute incidence of excess serious CV thrombotic events, due to their increased baseline rate. The increase in CV thrombotic risk has been observed most consistently at higher doses To minimize the potential risk for an adverse CV event in NSAID-treated patients, use the lowest effective dose for the shortest duration possible. Avoid the use of ibuprofen tablets in patients with a recent MI unless the benefits are expected to outweigh the risk of recurrent CV thrombotic events. If ibuprofen tablets are used in patients with a recent MI, monitor patients for signs of cardiac ischemia NSAIDs, including ibuprofen tablets should be used with caution in patients with hypertension. Blood pressure (BP) should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy Use of Ibuprofen may blunt the CV effects of several therapeutic agents used to treat these medical conditions [e.g., diuretics, ACE inhibitors, or angiotensin receptor blockers (ARBs)]

Patients with angina that take ibuprofen are at a higher risk of serious CV thrombotic events, due to their increased baseline rate of CV disease.

• The risk of CV thrombotic events is higher in patients with known CV disease or risk factors.
• Monitoring of patients with angina that take ibuprofen is necessary to minimize the potential risk for an adverse CV event.
• Lowest effective dose for the shortest duration possible should be used to reduce the risk of CV thrombotic events.
• Blood pressure should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy.
• Caution should be used when prescribing ibuprofen to patients with hypertension or recent MI 2.

From the Research

Effects of Ibuprofen on Angina

• Ibuprofen is a Non-Steroidal Anti-Inflammatory Drug (NSAID) that can interact with other medications, including those used to treat angina 3.
• The use of ibuprofen in patients with angina may not be directly addressed in the provided studies, but it is known that NSAIDs can interfere with the antiplatelet effect of aspirin, which is often used to prevent cardiovascular events in patients with angina 4.
• However, one study suggests that the use of ibuprofen according to over-the-counter (OTC) guidelines in patients taking cardioprotective doses of aspirin does not appear to interfere with aspirin's antiplatelet activity 3.

Angina Treatment and Management

• Angina pectoris is a condition characterized by chest pain or discomfort due to transient myocardial ischemia, and its management involves lifestyle modification, pharmaceutical interventions, and physical interventions 5, 6.
• The goal of angina treatment is to reduce myocardial oxygen demand and improve oxygen delivery to the heart, and this can be achieved through various mechanisms, including heart rate modulation, vascular smooth muscle relaxation, and metabolic manipulation 5.
• Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, can be used to improve angina symptoms, and revascularization with percutaneous coronary intervention may be reserved for patients in whom angina symptoms negatively influence quality of life 6.

Considerations for Patients with Angina Taking Ibuprofen

• Patients with angina who take ibuprofen should be aware of the potential interactions between ibuprofen and other medications, including aspirin, and should consult their healthcare provider before taking any new medications 4, 3.
• The use of ibuprofen in patients with angina should be carefully considered, taking into account the potential benefits and risks, and alternative treatments should be explored if necessary 6.