From the Guidelines
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are contraindicated in Congestive Heart Failure (CHF) because they can worsen HF symptoms and increase the risk of hospitalization.
Reasons for Contraindication
- Sodium and water retention: NSAIDs can cause sodium and water retention, which can worsen HF symptoms and increase the risk of hospitalization 1.
- Blunting of diuretic effects: NSAIDs can blunt the effects of diuretics, which are commonly used to treat HF, by inhibiting the synthesis of renal prostaglandins that mediate vasodilation in the kidneys and directly inhibit sodium resorption in the thick ascending loop of Henle and collecting tubule 1.
- Increased risk of morbidity and mortality: Several observational cohort studies have revealed increased morbidity and mortality in patients with HF using either nonselective or selective NSAIDs 1.
- Renal strain: Many people with HF also have renal dysfunction and take a loop diuretic and ACE inhibitor—adding NSAID increases renal strain, particularly in the older adult 1.
Clinical Implications
- Avoidance of NSAIDs: NSAIDs should be avoided in patients with HF, and alternative treatments for pain and inflammation should be considered, such as paracetamol or topical NSAIDs 1.
- Monitoring of patients on NSAIDs: Patients with HF who are taking NSAIDs should be closely monitored for signs of worsening HF symptoms and renal dysfunction 1.
From the Research
Mechanism of NSAIDs in Congestive Heart Failure (CHF)
- The inhibition of prostaglandin synthesis by NSAIDs may adversely affect cardiovascular homeostasis in patients with a propensity to develop CHF 2.
- The use of NSAIDs can lead to a decrease in the efficacy of diuretics, which can induce CHF in patients treated with diuretics 3.
Risk of CHF Associated with NSAIDs
- The use of NSAIDs (other than low-dose aspirin) in the previous week was associated with a doubling of the odds of a hospital admission with CHF (adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.3) 4.
- Use of NSAIDs by patients with a history of heart disease was associated with an odds ratio of 10.5 (95% confidence interval, 2.5-44.9) for first admission with heart failure, compared with 1.6 (95% confidence interval, 0.7-3.7) in those without such a history 4.
- The odds of a first admission to a hospital with CHF was positively related to the dose of NSAID consumed in the previous week, and was increased to a greater extent with long half-life than with short half-life drugs 4.
Specific Patient Populations
- In patients with prevalent heart failure, current use of NSAIDs is associated with a substantially increased risk of a relapse (univariate and adjusted relative risks of 3.8 and 9.9, respectively) 5.
- The use of NSAIDs in elderly patients taking diuretics is associated with a 2-fold increased risk of hospitalization for CHF, especially in those with existing serious CHF 3.
Clinical Implications
- NSAIDs should be used with caution in patients with a history of cardiovascular disease 4.
- Prescribing doctors have heeded advice about the cardiovascular risks of NSAIDs and extended this practice to selective COX-2 inhibitors, as evidenced by the lower relative risk estimates in recent studies compared to initial studies published in 1998-2000 6.