By STEVEN GEORGESON, MD
Nonsteroidal anti-inflammatory drugs (NSAIDs) are common medications, available over the counter as well as by prescription, used to relieve pain, reduce fever and decrease inflammation caused by arthritis, low back problems and soft tissue injury. There are many NSAIDs on the market including ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve), indomethacin (Indocin), diclofenac (Voltaren) and celecoxib (Celebrex). NSAIDs have been around since the 1960’s and may be the most widely prescribed class of medications in the world. Along with their beneficial effects, NSAIDs have significant side effects including gastrointestinal bleeding, kidney problems and several adverse cardiac effects. What are the cardiac side effects and how important are they?
Can NSAIDs increase the risk for a heart attack? Heart attacks occur when a plaque in a heart artery ruptures, a blood clot is formed over the rupture and blood flow to the heart muscle is stopped. Plaque in a heart artery is comprised of cholesterol and inflammation is felt to play an important role in plaque buildup. In fact, in addition to their usual properties, aspirin and statins are felt to lower the risk for a heart attack due to their anti-inflammatory effects. Do the anti-inflammatory effects of NSAIDs provide the same protection against heart attacks? Unfortunately, the answer is no. Prior to 2004, NSAIDs were felt to be safe for heart patients. In 2004, the NSAID rofecoxib (Vioxx) was removed from the market due to its increased risk for heart attack and stroke, especially with prolonged use and at high doses. After the withdrawal of Vioxx, a large study testing the heart risks of many NSAIDs was performed and recently concluded. The study found that all NSAIDs (including Naprosyn, which was thought to have acceptable cardiac safety) increased the risk for heart attack. The risk starts in the first week, is greatest in the first month of usage and is increased at high doses.
Can NSAIDs increase blood pressure and cause swelling? If a patient goes to the doctor with new onset of swelling in the legs or with an increase in blood pressure, one of the first questions asked is whether the patient is taking an NSAID. NSAIDs mechanism of action is to reduce certain factors that result in inflammation. Unfortunately, those same factors have a good effect on kidney function. Reducing these factors leads to a reduction in the blood flow to the kidneys. If the blood flow to the kidneys decreases, the kidneys feel the body is dehydrated and respond by retaining more sodium (salt) and water. This leads to increased swelling and an increase in blood pressure. In addition, NSAIDs can block the effect of certain high blood pressure medications (ACE or ARBs), leading to hormonal activation and further retention of salt and water. Due to these effects, all NSAIDs have warnings on their labels stating that they may increase blood pressure or cause swelling.
Can NSAIDs cause congestive heart failure (CHF)? The link between NSAIDs and CHF has been known for more than 20 years. NSAIDs can cause CHF in several ways. NSAIDs can increase the blood pressure, increasing the workload of the heart. If there is a weakened heart for any reason, that extra workload can tip the heart into CHF. In addition, if more salt and water is retained in a patient with a weak heart, the excess fluid accumulates in the lungs and CHF occurs. In fact, the use of any NSAID was associated with a 19% increase in admission to the hospital for CHF.
All this data does not imply that NSAIDs are bad drugs or drugs that should be avoided. On the other hand, NSAIDS are not harmless over the counter medications that can be taken without risk. Patients who are at a high risk for a heart attack, patients with CHF or high blood pressure perhaps should avoid NSAIDs or use them at the lowest possible dose and for a short period of time. Low risk patients should be able to take NSAIDs with appropriate caution.
Bridgewater resident Steve Georgeson is a cardiologist who works for Medicor Cardiology. Here, he writes about topics and events pertaining to cardiology.