From the Guidelines
Patients with Coronary Artery Disease (CAD) should avoid taking Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) due to the increased risk of cardiovascular events. The use of NSAIDs in patients with CAD can lead to adverse outcomes, including increased blood pressure, worsening heart failure, and a higher risk of heart attack or stroke, particularly with prolonged use or at higher doses 1. When pain relief is necessary, acetaminophen is generally a safer alternative for CAD patients, with a recommended daily dose not exceeding 3,000 mg. For those who must use NSAIDs, the lowest effective dose for the shortest duration is recommended, with naproxen potentially offering a slightly better cardiovascular safety profile compared to other NSAIDs 1. It is crucial for patients to consult their cardiologist before taking any NSAID, especially if they have had a recent heart attack, have heart failure, or are taking aspirin for heart protection. The cardiovascular risks associated with NSAIDs are attributed to their inhibition of protective prostaglandins that maintain blood vessel health and blood pressure regulation, as well as their potential to interfere with the cardioprotective effects of aspirin. Key considerations for managing pain in CAD patients include:
- Avoiding NSAIDs whenever possible
- Using acetaminophen as a safer alternative
- Consulting a cardiologist before initiating NSAID therapy
- Minimizing NSAID dose and duration when absolutely necessary
- Being aware of the potential interactions between NSAIDs and other cardiovascular medications, such as aspirin. Given the potential risks, the most recent and highest quality evidence supports avoiding NSAIDs in patients with CAD to minimize adverse cardiovascular outcomes 1.
From the FDA Drug Label
NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk Patients with known CV disease or risk factors for CV disease may be at greater risk. Naproxen is contraindicated for the treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery NSAID medicines may increase the chance of a heart attack or stroke that can lead to death. This chance increases: with longer use of NSAID medicines in people who have heart disease
Key Points:
- Patients with Coronary Artery Disease (CAD) or risk factors for cardiovascular disease may be at greater risk for serious cardiovascular events when taking NSAIDs.
- NSAIDs can increase the chance of a heart attack or stroke, especially with longer use in people with heart disease.
- Naproxen is contraindicated for peri-operative pain in CABG surgery.
Answer: Patients with CAD should avoid taking NSAIDs due to the increased risk of serious cardiovascular events, such as heart attack or stroke. 2, 2, 2
From the Research
NSAIDs and CAD: An Overview
- Patients with Coronary Artery Disease (CAD) should exercise caution when taking Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) due to potential increased cardiovascular risks 3, 4, 5.
- Studies have shown that NSAID use can lead to an increased risk of major adverse cardiac events (MACEs), including incident myocardial infarction, coronary intervention, and death 3, 6, 7.
Specific NSAIDs and CAD Risks
- Naproxen is associated with the smallest risk increase of cardiovascular events among NSAIDs 5, 7.
- Diclofenac seems to carry the greatest risk of cardiovascular events in patients with a history of coronary artery disease 5, 7.
- Ibuprofen, celecoxib, and rofecoxib have also been shown to increase the risk of serious coronary heart disease and cardiovascular disease/death 7.
Clinical Implications
- The absolute risk differences and numbers needed to harm were considered clinically relevant, particularly in patients with non-obstructive CAD 3.
- Clinicians should carefully weigh the benefits and risks of NSAID use in patients with CAD and consider alternative therapies when possible 4, 5.
- Patients with CAD should be closely monitored for cardiovascular events when taking NSAIDs, and the lowest effective dose should be used for the shortest duration necessary 6, 7.