Does a history of cerebrovascular accident (CVA) limit the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?

NSAIDs in Patients with History of Cerebrovascular Accident (CVA)

A history of cerebrovascular accident (CVA) warrants caution when using NSAIDs, but does not absolutely contraindicate their use. 1 While NSAIDs are associated with increased cardiovascular risks, the evidence suggests that the risk varies by specific NSAID, dosage, duration, and individual patient factors.

Risk Assessment for NSAIDs After CVA

The 2011 AHA/ASA guidelines note that in a population-based stroke registry, NSAIDs were not associated with either increased risk of hemorrhagic stroke or protection against initial ischemic stroke 1. However, more recent evidence provides important considerations:

• NSAIDs can lead to:

  • New hypertension or worsening of pre-existing hypertension 2
  • Fluid retention and edema 2
  • Increased risk of serious cardiovascular thrombotic events 2

• Risk factors that require additional caution:

  • Age >60 years 3
  • Pre-existing cardiovascular disease 2
  • Hypertension 2
  • Heart failure 2
  • Concurrent use of anticoagulants or antiplatelet agents 2

NSAID Selection After CVA

When NSAIDs must be used in patients with CVA history, the choice of agent matters:

• Naproxen appears to have a lower cardiovascular risk profile compared to other NSAIDs 4, with one study showing no significant association with increased stroke risk (OR 0.92; 95% CI 0.67-1.26) 3

• Avoid diclofenac which shows a significantly increased risk of ischemic stroke (OR 1.53; 95% CI, 1.19-1.97), particularly with high doses, long-term use, and in patients with high cardiovascular risk 5

• Low-dose ibuprofen may have a relatively lower cardiovascular risk profile 4, with one study showing no significant association with stroke (OR = 0.94; 0.76-1.17) 5

• Highly COX-2 selective NSAIDs are associated with a 61% increase in CVA risk compared to poorly selective NSAIDs 6

Recommendations for NSAID Use in CVA Patients

1. Use the lowest effective dose for the shortest duration possible 2

2. Monitor closely:

   • Blood pressure before and during NSAID therapy 3
   • Renal function (BUN, creatinine) 3
   • Signs of fluid retention or edema 2

3. Consider alternative pain management options:

   • Acetaminophen (up to 3g/day) as first-line therapy 3
   • Topical NSAIDs for localized pain 3
   • Topical lidocaine or capsaicin 3
   • Physical therapy and appropriate exercise 3
   • Short-term, carefully monitored opioid therapy when other options fail 3

Important Precautions

• Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs 2

• Concomitant use of aspirin with NSAIDs increases gastrointestinal bleeding risk without clearly mitigating cardiovascular risk 2

• The risk of adverse cardiovascular events may increase within weeks of starting NSAID therapy, particularly with higher doses 4

• If NSAIDs must be used, consider adding a proton pump inhibitor to reduce gastrointestinal bleeding risk 3

In conclusion, while a history of CVA does not absolutely contraindicate NSAID use, it should prompt careful consideration of alternatives, selection of lower-risk agents when NSAIDs are necessary, use of the lowest effective dose for the shortest duration, and close monitoring for adverse effects.