Can a patient with a history of myocardial infarction (MI), coronary artery bypass graft (CABG), and recently diagnosed sciatica with severe pain take nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen (Naprosyn) 500mg twice daily (bid)?

From the Guidelines

NSAIDs like naproxen 500mg twice daily are not recommended for patients with a history of myocardial infarction (MI), stent placement, and coronary artery bypass graft (CABG) due to increased cardiovascular risk, as evidenced by studies such as Gislason et al. 1. Despite the patient's sciatica pain, the use of NSAIDs can promote thrombosis, raise blood pressure, and potentially interfere with the antiplatelet effects of medications like aspirin, which is a significant concern in patients with established cardiovascular disease. The American College of Cardiology/American Heart Association guidelines recommend a stepped-care approach to pain management, starting with acetaminophen or aspirin, small doses of narcotics, or non-acetylated salicylates 1. If pain remains severe, non-selective NSAIDs like naproxen may be considered, but with caution and at the lowest effective dose for the shortest possible time, as they have been associated with increased cardiovascular risk, particularly in patients with established cardiovascular disease 1. Safer alternatives for sciatica pain management should be considered first, including:

• Acetaminophen (up to 3000mg daily in divided doses)
• Physical therapy
• Topical analgesics
• Possibly gabapentin or pregabalin for neuropathic pain If a short course of NSAIDs is necessary, it is crucial to discuss the risks and benefits with the patient's cardiologist and closely monitor for cardiovascular symptoms, renal function, and blood pressure.

From the FDA Drug Label

NSAID medicines may increase the chance of a heart attack or stroke that can lead to death. This chance increases: with longer use of NSAID medicines in people who have heart disease NSAID medicines should never be used right before or after a heart surgery called a "coronary artery bypass graft (CABG). "

The patient has a history of MI stent and CABG, and recently diagnosed with sciatica. Considering the patient's history of heart disease and CABG, the use of NSAIDs like naproxen may increase the chance of a heart attack or stroke.

• The patient should not take NSAID medicines right before or after a heart surgery called a "coronary artery bypass graft (CABG)".
• Naproxen 500mg bid may not be the best option for this patient due to the increased risk of heart attack or stroke.
• The patient's healthcare provider should be consulted to determine the best course of treatment for the patient's sciatica and to weigh the potential benefits and risks of using naproxen 2.

From the Research

Patient History and Current Condition

• The patient has a history of myocardial infarction (MI), stent placement, and coronary artery bypass grafting (CABG).
• The patient has recently been diagnosed with sciatica and is experiencing severe pain.
• The question is whether the patient can take nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen 500mg twice a day.

Considerations for NSAID Use

• Studies have shown that prior coronary stenting does not significantly influence CABG outcome 3, 4.
• However, the use of NSAIDs in patients with coronary stents may be a concern due to the potential risk of cardiovascular events.
• One study found that the use of nonselective NSAIDs or COX-2 inhibitors was not associated with an increased rate of major adverse cardiovascular events (MACE) in patients with coronary stents 5.
• Another study found that CABG plus optimal medical therapy reduced nonfatal myocardial infarction compared to optimal medical therapy alone, whereas PCI did not 6.

NSAID Use in Patients with Coronary Stents

• The study by 5 suggests that the use of NSAIDs in patients with coronary stents may not be associated with an increased risk of cardiovascular events.
• However, it is essential to note that individual NSAIDs may have different effects, and the study could not rule out small risks associated with individual NSAIDs.
• The decision to use NSAIDs in this patient should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.

Sciatica and Pain Management

• The patient's recent diagnosis of sciatica and severe pain should be considered when deciding on pain management options.
• NSAIDs like naproxen may be effective in managing pain and inflammation associated with sciatica.
• However, the patient's cardiovascular history and potential risks associated with NSAID use should be carefully weighed against the benefits of pain management.