After Heart Attack, Certain Painkillers May Raise Risk for Recurrence
MONDAY May 9, 2011 -- People with a history of heart attack are at increased risk of suffering another attack or dying after even a week of taking certain types of prescription and over-the-counter painkillers, including Advil, Motrin or Voltaren, a large new study suggests.
Danish researchers analyzed nationwide records of almost 84,000 heart attack survivors and found that those who used certain non-steroidal anti-inflammatory drugs (NSAID) for one week faced a 45 percent heightened risk of another heart attack. Three months' use raised the risk to 55 percent.
The results reinforce a 2007 American Heart Association statement advising doctors about the risk of NSAID use among heart patients and recommending the drugs be used only in the lowest dose and for the shortest duration necessary.
"The present results indicate there is no apparent safe therapeutic window for NSAIDs in patients with prior [heart attack], and challenge the current recommendations of low-dose and short-term use of NSAIDs as being safe," said study author Dr. Anne-Marie Schjerning Olsen, a research fellow at Copenhagen University in Denmark.
The study is published online May 9 in the journal Circulation.
The most common NSAIDs prescribed to study participants were ibuprofen (Advil, Motrin) and diclofenac (Cataflam, Voltaren). Diclofenac carried the highest cardiovascular risk, even greater than rofecoxib (Vioxx), an NSAID banned in the United States in 2004 because of a higher rate of heart attacks and strokes among those taking it.
The U.S. Food and Drug Administration recently issued a warning that diclofenac should not be used by patients recovering from heart surgery.
One popular NSAID, naproxen (Aleve), was not associated with a greater risk of death or recurrent heart attack in the study, although it has been linked to gastrointestinal bleeding.
"We were surprised that commonly used NSAIDs such as diclofenac, which in some countries is available over the counter without any expert advice on potential side effects, were associated with increased risk ... and the risk continued to persist during the course of treatment," Olsen said.
All NSAIDs block the production of the COX enzyme, which comes in two forms. Drugs inhibiting the COX-2 enzyme (these include Celebrex) have a higher chance of associated blood clots than other NSAIDs inhibiting the COX-1 type, said Dr. Elliott Antman, professor of medicine at Brigham and Women's Hospital and Harvard Medical School in Boston.
"For example, aspirin -- an NSAID with blood-thinning properties -- blocks the COX-1 enzyme," Antman noted, "and has long been considered useful in preventing heart attacks when used in low doses." Both Antman and Olsen agreed that, at the low dose typically given to patients, daily aspirin should pose no added risk for recurrence of heart attack.
Otherwise, the results of the new "are not surprising to us, and we felt it actually endorsed the recommendations we made," said Antman, who was also the lead author of the AHA's 2007 NSAIDs advisory.
"We felt there was a risk of using NSAIDs if the patient had ischemic heart disease or was at risk for it . . . we were not convinced for any period of time that these were safe," Antman added.
Olsen and her team noted that the new study was limited by its observational nature, and a prospective, randomized trial would bring more certainty on the issue. But the data was comprehensive because it came from the Danish National Patient Registry, she said, as well as a national prescription registry that has recorded every drug prescribed to citizens since 1997.
Among the nearly 84,000 heart attack survivors analyzed, whose average age was 68, more than 42 percent had at least one prescription for an NSAID, according to the study. Low-dose ibuprofen is the only NSAID available over-the-counter in Denmark, so its use was unlikely to significantly affect study results, Olsen said.
Antman said heart patients will sometimes use NSAIDs despite the risks if they suffer severe pain from conditions such as rheumatoid arthritis or lupus. Non-drug pain relief methods, such as physical therapy, heat and splints, or other types of pain relievers should be tried before resorting to NSAIDS, he said.
"Some patients have such debilitating arthritis that we need to work down the list [of NSAIDs], recognizing as we get down the list we're getting into increasingly dangerous territory," Antman said.
"If they're on one, they shouldn't stay on it. Many doctors don't monitor medication use and patients stay on long past flare-ups."
The American Academy of Orthopaedic Surgeons has more information about NSAIDs.
Posted: May 2011