From the Guidelines
A history of CABG and MI is considered a contraindication for NSAIDs due to the increased risk of cardiovascular events. According to the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1, NSAIDs with increasing degrees of relative COX-2 selectivity should not be administered to patients with established cardiovascular disease, such as those with a history of CABG and MI. The guideline states that selective COX-2 inhibitors and other nonselective NSAIDs have been associated with increased cardiovascular risk, which appears to be amplified in patients with established cardiovascular disease.
Some key points to consider when managing pain in patients with a history of CABG and MI include:
- Avoiding NSAIDs, especially COX-2 selective inhibitors like celecoxib and diclofenac, due to their high cardiovascular risk 1
- Considering acetaminophen as a first-line alternative for pain management
- Using the lowest effective dose of NSAIDs for the shortest possible duration if they are absolutely required
- Being aware that all NSAIDs, except aspirin in low doses, can increase cardiovascular risk
The increased cardiovascular risk associated with NSAIDs is thought to be due to their ability to inhibit production of protective prostaglandins, increase blood pressure, promote fluid retention, and potentially interfere with the cardioprotective effects of aspirin when used concurrently. Therefore, it is recommended to avoid NSAIDs in patients with a history of CABG and MI, and to consider alternative pain management options.
From the FDA Drug Label
NSAIDs are contraindicated in the setting of CABG [see Contraindications (4)] Avoid the use of celecoxib capsules in patients with a recent MI unless the benefits are expected to outweigh the risk of recurrent CV thrombotic events. NSAIDs are contraindicated in the setting of CABG [see CONTRAINDICATIONS] Avoid the use of ibuprofen tablets in patients with a recent MI unless the benefits are expected to outweigh the risk of recurrent CV thrombotic events. Ibuprofen Tablets are contraindicated in the setting of coronary artery bypass graft (CABG) surgery [see CONTRAINDICATIONS and WARNINGS].
History of CABG and MI is considered a contraindication of NSAIDs.
- Patients with a history of CABG or recent MI should avoid using NSAIDs unless the benefits outweigh the risk of recurrent CV thrombotic events 2, 3, 3.
- The use of NSAIDs in these patients may increase the risk of serious CV thrombotic events, including myocardial infarction and stroke.
From the Research
History of CABG and MI as a Contraindication of NSAIDs
- A history of Coronary Artery Bypass Grafting (CABG) and Myocardial Infarction (MI) is considered a significant risk factor when prescribing Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) due to the potential for increased cardiovascular risk 4, 5.
- Studies have shown that NSAID treatment is associated with an increased risk of death and recurrent MI in patients with prior MI, with the risk persisting throughout the treatment course 4.
- The use of NSAIDs in patients receiving antithrombotic therapy after MI is also associated with an increased risk of bleeding and cardiovascular events, regardless of the type of NSAID or duration of use 5.
Cardiovascular Risk of NSAIDs
- The cardiovascular risk of NSAIDs is a class effect, but the magnitude of the risk varies widely between individual NSAID drugs 6, 7.
- Selective COX-2 inhibitors, such as celecoxib, may be associated with an increased risk of cardiovascular events, but the risk is likely to be small and similar to that of nonselective NSAIDs 6, 8.
- The potential cardiovascular risk of NSAIDs must be weighed against the potential benefits in each individual, and NSAIDs should be used at the lowest effective dose for the shortest possible duration 8, 7.
Clinical Implications
- Physicians should exercise caution when prescribing NSAIDs to patients with a history of CABG and MI, and consider alternative treatments when possible 4, 5.
- Patients with a history of cardiovascular disease should be closely monitored for signs of cardiovascular events when taking NSAIDs, and the benefits and risks of NSAID therapy should be carefully evaluated 7.