From the Guidelines
NSAIDs are contraindicated in Coronary Artery Disease (CAD) due to their significant cardiovascular risks, including increased mortality, reinfarction, hypertension, heart failure, and myocardial rupture, as evidenced by the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines 1. The use of NSAIDs in CAD patients can lead to a disruption in the balance between thromboxane and prostacyclin, promoting platelet aggregation and vasoconstriction, which can increase the risk of heart attack, stroke, and heart failure exacerbation. Additionally, NSAIDs can cause sodium and water retention, increasing blood pressure and potentially worsening heart failure, and can also interfere with the cardioprotective effects of aspirin and reduce the effectiveness of certain antihypertensive medications. Key points to consider when managing CAD patients include:
- Avoiding the use of NSAIDs, except for ASA, in patients with unstable angina or non-ST-elevation myocardial infarction (UA/NSTEMI) 1
- Considering alternative pain relief options, such as acetaminophen (Tylenol), for CAD patients requiring pain management
- Using the lowest effective dose of an NSAID for the shortest possible duration, if NSAID use is necessary, after careful risk assessment and preferably under medical supervision 1
- Being aware of the increased cardiovascular risk associated with selective COX-2 inhibitors and other nonselective NSAIDs, particularly in patients with established cardiovascular disease (CVD) 1.
From the Research
NSAIDs Contraindication in CAD
NSAIDs are contraindicated in Coronary Artery Disease (CAD) due to the increased risk of adverse cardiovascular events. The following points summarize the key findings:
- NSAID use is associated with an increased risk of major adverse cardiac events (MACEs), including incident myocardial infarction, coronary intervention, and death 2.
- The rate of MACE increases by 33% for any NSAID use compared with non-use in patients with no CAD, and by 48% in patients with non-obstructive CAD 2.
- Current use of older cyclooxygenase-2 inhibitors is associated with the highest hazard ratio in patients with non-obstructive CAD 2.
- The use of NSAIDs, both traditional and cyclo-oxygenase 2 (COX-2) selective, is associated with an increased risk of adverse cardiovascular events, myocardial infarction, heart failure, and cerebrovascular events in patients with and without CV diseases 3.
- Naproxen and low-dose ibuprofen appear to have a lower increased CV risk among NSAIDs, while COX-2 inhibitors have a more favorable GI risk profile 3.
Cardiovascular Risks
The cardiovascular risks associated with NSAID use in CAD patients include:
- Increased risk of myocardial infarction, stroke, hypertension, heart failure, and atrial fibrillation 4.
- Increased risk of serious coronary heart disease and serious cardiovascular disease/death, particularly with short-term use of ibuprofen, diclofenac, celecoxib, and rofecoxib 5.
- Naproxen has been found to have better cardiovascular safety than diclofenac, ibuprofen, and higher doses of celecoxib and rofecoxib in patients recently hospitalized for serious coronary heart disease 5.
Safety and Efficacy
The safety and efficacy of anti-inflammatory therapy in patients with CAD have been evaluated in several studies:
- Anti-inflammatory therapy can reduce the incidence of the primary outcome in patients with CAD, especially the risk of MI and coronary revascularization 6.
- However, anti-inflammatory therapy increases the risk of infection 6.
- The use of NSAIDs should be optimized by using the lowest effective dose for the shortest amount of time, especially among individuals with increased CV risk 3.