What are the considerations for using Naproxen (nonsteroidal anti-inflammatory drug (NSAID)) in patients with heart failure?

From the Guidelines

Naproxen should be used with extreme caution in patients with heart failure, and is generally not recommended for these patients. This NSAID can worsen heart failure by causing sodium and fluid retention, increasing blood pressure, and reducing kidney function, as noted in the guidelines for the diagnosis and management of heart failure in adults 1. The use of naproxen in patients with heart failure can lead to adverse effects such as:

• Sodium retention and peripheral vasoconstriction
• Attenuation of the efficacy and enhancement of the toxicity of diuretics and ACEIs
• Increased risk of cardiovascular events Patients with heart failure who absolutely require pain management with NSAIDs should use the lowest effective dose for the shortest possible duration, with close monitoring of their heart failure symptoms, weight, blood pressure, and kidney function, as recommended in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Alternative pain management strategies should be considered first, such as acetaminophen, topical analgesics, or non-pharmacological approaches. If naproxen must be used, patients should be instructed to immediately report worsening shortness of breath, sudden weight gain, increased swelling in the legs or ankles, or decreased urine output, as these may indicate worsening heart failure. The cardiovascular risks of naproxen are related to its mechanism of action - inhibition of prostaglandin synthesis affects renal blood flow and vascular tone, leading to these adverse effects in heart failure patients. Key considerations for using naproxen in patients with heart failure include:
• Close monitoring of heart failure symptoms and kidney function
• Use of the lowest effective dose for the shortest possible duration
• Alternative pain management strategies should be considered first
• Patients should be instructed to report any signs of worsening heart failure immediately.

From the FDA Drug Label

WARNINGS CARDIOVASCULAR EFFECTS Cardiovascular Thrombotic Events Clinical trials of several COX-2 selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, myocardial infarction, and stroke, which can be fatal. Naproxen should be used with caution in patients with fluid retention, hypertension, or heart failure Congestive Heart Failure and Edema Fluid retention, edema, and peripheral edema have been observed in some patients taking NSAIDs.

Key Considerations:

• Caution is advised when using Naproxen in patients with heart failure due to the potential for fluid retention and worsening of pre-existing hypertension.
• Monitoring of blood pressure is recommended during the initiation of NSAID treatment and throughout the course of therapy.
• The lowest effective dose should be used for the shortest duration possible to minimize the potential risk for an adverse CV event.
• Patients with known CV disease or risk factors for CV disease may be at greater risk 2.
• Naproxen is contraindicated for the treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery 2.

From the Research

Considerations for Using Naproxen in Patients with Heart Failure

• Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), can have negative effects on patients with heart failure, including worsening of cardiac function and increased risk of heart failure symptoms 3, 4.
• The use of NSAIDs, including naproxen, can lead to renal dysfunction, water and sodium retention, and decreased renal blood flow and glomerular filtration rate, which can exacerbate heart failure 4.
• Studies have shown that naproxen can decrease urinary excretion of water, sodium, and chloride, and decrease osmolal clearance, which can worsen heart failure 5.
• Naproxen has been shown to aggravate doxorubicin-induced cardiomyopathy in rats, suggesting that it may have cardiotoxic effects 6.
• Epidemiological studies have found that the use of NSAIDs, including naproxen, is associated with an increased risk of hospital admission for congestive heart failure, particularly in patients with a history of heart disease 7.

Key Findings

• Naproxen can worsen heart failure symptoms and cardiac function 3, 4.
• Naproxen can lead to renal dysfunction and exacerbate heart failure 4, 5.
• Naproxen may have cardiotoxic effects and aggravate cardiomyopathy 6.
• The use of NSAIDs, including naproxen, is associated with an increased risk of hospital admission for congestive heart failure 7.

Implications for Clinical Practice

• Naproxen should be used with caution in patients with heart failure, particularly those with a history of cardiovascular disease 3, 4, 7.
• Patients with heart failure should be closely monitored for signs of worsening cardiac function and renal dysfunction when using naproxen 4, 5.
• Alternative treatments, such as acetaminophen, tramadol, or Percocet, may be considered for patients with arthritis and heart failure who require pain relief 3.