Is ibuprofen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) contraindicated in patients with Acute Coronary Syndrome (ACS)?

Ibuprofen Contraindication in Acute Coronary Syndrome

Ibuprofen is contraindicated in patients with Acute Coronary Syndrome (ACS) due to increased cardiovascular thrombotic risk and potential interference with the cardioprotective effects of aspirin. 1, 2

Mechanisms of Harm in ACS

• NSAIDs, including ibuprofen, are associated with increased risk of major adverse cardiovascular events (MACE) in patients with and without prior cardiac disease 2
• Ibuprofen specifically interferes with aspirin's cardioprotective effects through competitive interaction at the COX-1 binding site 3
• NSAIDs cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal 1
• The FDA label explicitly states that ibuprofen is contraindicated in the setting of coronary artery bypass graft (CABG) surgery, highlighting its risks in cardiac patients 1

Interaction with Standard ACS Therapy

• Aspirin is a cornerstone medication in ACS management, with a Class I, Level A recommendation for all patients without contraindications 2
• When ibuprofen is taken with aspirin, it can diminish aspirin's protective antiplatelet effects, potentially increasing the risk of recurrent ACS events 2
• If ibuprofen must be used in a patient on aspirin therapy, it should be taken either at least 30 minutes after immediate-release aspirin or at least 8 hours before aspirin ingestion to minimize interference 2, 3
• No recommendations about the concomitant use of ibuprofen and enteric-coated low-dose aspirin can be made based on available data 2

Alternative Pain Management in ACS

• For pain management in ACS, guidelines recommend:
  • Nitroglycerin (sublingual or IV) as first-line therapy 2
  • Opioids such as morphine or fentanyl for pain resistant to anti-ischemic medications 2
• Acetaminophen may be considered as an alternative to NSAIDs for pain management in ACS patients, though caution is still warranted 3

Clinical Implications

• Withdrawal or discontinuation of antiplatelet therapy has been associated with recurrent episodes of ACS, including stent thrombosis 2, 3
• The 2025 ACC/AHA guidelines explicitly state: "Use of nonaspirin nonsteroidal anti-inflammatory drugs should be avoided for management of suspected or known ischemia pain whenever possible" 2
• Patients with ACS are at particularly high risk of bleeding complications when NSAIDs are added to antiplatelet therapy 3
• Elderly patients are at greater risk for serious gastrointestinal events with NSAID use 1

Practical Recommendations

• Completely avoid ibuprofen and other NSAIDs in ACS patients whenever possible 2
• For pain management in ACS, use the recommended alternatives: nitroglycerin, morphine, or fentanyl as appropriate 2
• If an NSAID must be used (though this is strongly discouraged), consider adding a proton pump inhibitor to reduce gastrointestinal bleeding risk 3
• Patient education about the risks of NSAID use in ACS is essential to prevent self-medication with over-the-counter ibuprofen 3