Is diclofenac (non-steroidal anti-inflammatory drug (NSAID)) a suitable choice for a patient with tachycardia (abnormally fast heart rate)?

Diclofenac Should Be Avoided in Patients with Heart Rate Problems

For patients with tachycardia or other heart rate problems, diclofenac is NOT a suitable choice of NSAID due to its significantly increased cardiovascular risk profile compared to other options. 1

Cardiovascular Risks of Diclofenac

Diclofenac has been consistently associated with higher cardiovascular risks:

• Meta-analyses show diclofenac increases risk of serious cardiovascular events by approximately 40% compared to placebo 1
• Diclofenac has a hazard ratio of 2.40 (95% CI 2.09-2.80) for mortality in patients with prior myocardial infarction 1
• It increases risk of recurrent MI with a hazard ratio of 1.54 (95% CI 1.23-1.93) 1
• Diclofenac has similar cardiovascular risk profile to withdrawn COX-2 inhibitors like rofecoxib 2, 3

Better NSAID Alternatives for Patients with Heart Rate Problems

For patients with tachycardia requiring an NSAID, follow this stepped-care approach:

1. First-line options (safest cardiovascular profile):

   • Acetaminophen (not an NSAID but effective for pain)
   • Small doses of narcotics for short-term use
   • Nonacetylated salicylates

2. If first-line ineffective, consider:

   • Naproxen (has the lowest cardiovascular risk among NSAIDs)
     • Relative risk of 0.92 (95% CI 0.67-1.26) for vascular events 1, 4
     • No increased risk of death (HR 0.84; 95% CI 0.50-1.42) 5

3. Avoid if possible:

   • Diclofenac (highest CV risk)
   • High-dose ibuprofen (>1200mg/day)
   • COX-2 selective inhibitors

Special Considerations for Heart Rate Problems

• Monitor blood pressure within 1-2 weeks of starting any NSAID therapy 4
• NSAIDs can lead to fluid retention and edema, potentially worsening tachycardia 6
• NSAIDs may blunt effects of medications used to treat heart conditions (e.g., diuretics, ACE inhibitors, ARBs) 6
• Low-dose ibuprofen (≤1200mg/day) has a more favorable cardiovascular profile than diclofenac 2

Important Precautions

• If an NSAID must be used in a patient with cardiovascular risk factors, use the lowest effective dose for the shortest duration possible 1, 6
• For patients on aspirin therapy, be aware that ibuprofen may interfere with aspirin's cardioprotective effects 4
• NSAIDs can cause or worsen hypertension, which may exacerbate tachycardia 6
• All NSAIDs carry a black box warning regarding cardiovascular risk, but the magnitude varies significantly between agents 6

Common Pitfalls to Avoid

1. Assuming all NSAIDs have equal cardiovascular risk profiles
2. Prescribing diclofenac as first-line therapy due to its potent anti-inflammatory effects without considering cardiovascular safety
3. Failing to monitor blood pressure and heart rate after initiating NSAID therapy
4. Using higher doses than necessary, as cardiovascular risk is dose-dependent
5. Continuing NSAID therapy longer than needed, as risk increases with duration of use

In conclusion, when treating patients with tachycardia or other heart rate abnormalities who require anti-inflammatory therapy, naproxen is the safest NSAID option, while diclofenac should be avoided due to its significantly higher cardiovascular risk profile 1, 7.