Is naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) safe for pain relief in patients with multivessel Coronary Artery Disease (CAD) and Peripheral Vascular Disease (PVD) who are currently smoking?

Naproxen Use in High-Risk Cardiovascular Patients

Naproxen should be avoided in patients with multivessel CAD and PVD who are currently smoking, as this combination represents extremely high cardiovascular risk and NSAIDs increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke. 1

Risk Assessment in This Patient Population

Your patient has multiple cardiovascular risk amplifiers that dramatically increase their baseline risk:

• Multivessel CAD and PVD together are major risk factors for poor outcomes, with significantly higher mortality rates and risk of acute heart failure 2
• Peripheral vascular disease is associated with increased MACE (major adverse cardiac events), with PVD patients having more extensive underlying CAD 2, 3
• Current smoking status, while paradoxically associated with lower short-term mortality in acute coronary syndrome (due to younger age and less severe plaques), does not negate the long-term cardiovascular risk amplification 2
• The combination of multivessel CAD and PVD indicates polyvascular disease, which carries a 35% higher risk of all-cause death over 5 years 2

FDA Black Box Warning on Naproxen

The FDA explicitly warns that "NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk." 1

Additionally, naproxen can lead to new-onset hypertension or worsening of pre-existing hypertension, fluid retention, and edema—all of which contribute to increased cardiovascular events 1

Evidence-Based Alternative Approach

Use a stepped-care algorithm for pain management in this high-risk patient: 4, 5

First-Line Options (Start Here):

• Acetaminophen 4, 5
• Non-acetylated salicylates 4, 5
• Tramadol 4
• Small doses of narcotics 4, 5

Second-Line Consideration (Only if First-Line Insufficient):

• If an NSAID is absolutely necessary, naproxen ≤1000 mg/day has the most favorable cardiovascular safety profile among NSAIDs 4, 6, 7, 8
• However, even naproxen carries increased risk in patients with established cardiovascular disease 1, 9
• Use the lowest effective dose for the shortest possible duration 4, 1, 6, 7

Critical Monitoring if NSAID Use is Unavoidable:

• Monitor for sustained hypertension, edema, worsening renal function, or GI bleeding 4
• Blood pressure should be monitored closely during initiation and throughout therapy 1
• Consider adding low-dose aspirin (81mg) and a proton pump inhibitor if thrombotic risk is high 4

Important Caveats

• Avoid ibuprofen entirely if the patient is on aspirin therapy, as ibuprofen blocks aspirin's antiplatelet effects 4, 5
• The cardiovascular risk of NSAIDs is proportional to COX-2 selectivity and the patient's underlying cardiovascular risk 4, 9
• Diclofenac and coxibs carry the highest cardiovascular risk and should be absolutely avoided in this patient 6, 7, 8
• Even short-term NSAID therapy is not without cardiovascular risk 1, 9

Clinical Bottom Line

In a patient with multivessel CAD, PVD, and active smoking, the baseline cardiovascular risk is already substantially elevated. Adding naproxen would further increase the risk of MI, stroke, heart failure, and death. 1, 9 Prioritize non-NSAID analgesics and address the underlying pain etiology rather than accepting the compounded cardiovascular risk of NSAID therapy in this extremely high-risk patient.