NSAIDs Should Be Discontinued in Patients with Acute Ischemic Infarct and Hypertension
NSAIDs should be immediately discontinued in patients with acute ischemic infarct and high blood pressure due to increased risk of mortality, reinfarction, heart failure, and cardiovascular complications. 1, 2
Risks of NSAIDs in Acute Ischemic Infarct
- NSAIDs are associated with increased risk of death, reinfarction, heart failure, and shock in patients with acute myocardial infarction 1
- A secondary analysis of the EXTRACT-TIMI-25 data demonstrated increased risk of cardiovascular complications among patients taking NSAIDs within 7 days of enrollment 1
- NSAIDs are absolutely contraindicated during hospitalization for acute myocardial infarction 2
- Concomitant use of NSAIDs with antithrombotic therapy (common after MI) increases bleeding risk 3-6 fold 3, 4
- Even short-term NSAID treatment in patients with prior MI is associated with excess thrombotic events 4
Additional Cardiovascular Risks with Hypertension
- NSAIDs can increase blood pressure by an average of 5 mm Hg and may worsen heart failure 5
- The American Heart Association recommends avoiding NSAIDs in patients with congestive heart failure and using them with caution in those with hypertension 5
- NSAIDs increase the risk of ischemic stroke, with certain NSAIDs like diclofenac showing higher risk (OR = 1.53) 6, 7
- The risk is particularly elevated in patients with pre-existing cardiovascular risk factors 7
Risk Stratification by NSAID Type
- COX-2 selective inhibitors (e.g., celecoxib) have the highest risk of cardiovascular events in patients with prior MI 2
- Diclofenac is associated with significantly increased risk of ischemic stroke (OR = 1.53) 7
- Ibuprofen interferes with the cardioprotective effects of aspirin, which is commonly prescribed after MI 2
- Ketorolac shows the highest significant risk of ischemic stroke (OR = 1.46) 6
Alternative Pain Management Approaches
- Acetaminophen is a safer alternative for pain management in patients with cardiovascular disease 2
- Small doses of narcotics may be considered for short-term pain control 2
- Non-acetylated salicylates can be used as alternatives with potentially lower cardiovascular risk 2
Special Considerations for Intracerebral Hemorrhage
- In patients with spontaneous intracerebral hemorrhage (ICH), regular long-term use of NSAIDs is potentially harmful due to increased bleeding risk 1
- The risk of hemorrhagic stroke is increased with NSAID use, particularly with diclofenac and meloxicam 1
Monitoring Recommendations if NSAIDs Cannot Be Avoided
- If NSAIDs must be used (which is strongly discouraged), use the lowest effective dose for the shortest possible duration 2
- Monitor closely for signs of cardiac ischemia, heart failure exacerbation, hypertension, and bleeding 2
- Monitor renal function, as NSAIDs can cause volume-dependent renal failure and interstitial nephritis 5
- Consider gastrointestinal prophylaxis with a proton pump inhibitor if NSAID use is absolutely necessary 5, 3
In conclusion, the evidence strongly indicates that NSAIDs should be discontinued immediately in patients with acute ischemic infarct and hypertension due to significant cardiovascular risks including increased mortality, reinfarction, stroke, and heart failure exacerbation.