All common NSAIDs increase heart attack risk: A discussion with Dr. Michele Bally

Background:
Oral non-steroidal anti-inflammatory drugs (NSAIDs) are generally known to increase the risk of acute myocardial infarction. However, meta-analyses of NSAIDs and myocardial infarction risk in randomized controlled trials have not characterized the clinical reality of patients who use these drugs in low or varying doses, or intermittently, or who switch between various NSAIDs.

To that end, an international team of researchers carried out a systematic review of studies from Canadian and European health care databases involving 446,763 people, including 61,460 who had a heart attack.

The researchers published their results in a recent article in the British Medical Journal, in which they concluded that all commonly-used oral NSAIDs—ibuprofen, diclofenac, celecoxib, and naproxen—were associated with an increased risk of heart attack. The results also showed that people had the greatest risk during the first month of taking NSAIDs and when taking higher doses.

In this interview, lead author Michèle Bally, BPharm, MSc, PhD, discusses the results and implications of this study.

MDLinx: What is the impetus for this study? 

Dr. Bally: The dosages and the treatment durations studied in clinical trials may not represent the reality of many patients who use NSAIDs in low or varying doses, use these drugs on and off, or switch between NSAID medications. So the objective of this study was to better understand the risk of heart attack associated with using oral prescription NSAIDs the way people usually do to treat pain and inflammation in real-life circumstances.

MDLinx: What were the main findings of this study?

Dr. Bally: The study found that all commonly-prescribed NSAIDs—ibuprofen, diclofenac, celecoxib, and naproxen—were associated with an increased risk of heart attack. This heightened risk of heart attack occurred as early as in the first week of use. Also, the risk of heart attack was greater with higher doses of NSAIDs.

Use of NSAIDs in the first month at a high daily dose (celecoxib: >200 mg, diclofenac: >100 mg, ibuprofen: >1,200 mg, and naproxen: >750 mg) was associated with the greatest risk of heart attack. Using NSAIDs for longer than one month did not seem to continue to increase this heightened risk any further. However, we did not study repeat heart attacks.

MDLinx: What does this mean for the average patient who takes NSAIDs?

Dr. Bally: In general, people with heart disease or cardiac risk factors have a greater likelihood of heart attack following NSAID use than patients without these risk factors because they have a higher risk at baseline. People should be aware of their own baseline risk of heart disease and discuss use of NSAIDs with their health care providers, keeping in mind that on average the risk of a heart attack due to NSAIDs is only about 1% per year. 

Overall, the study found that a person’s baseline risk of a heart attack is increased by about 20% to 50% with the use of commonly available NSAIDs. For most people, this represents only a small risk increase over a person’s baseline risk. However, from the viewpoint of public health, even small increases in risk of heart attack are important because use of NSAIDs is so widespread.

MDLinx: What is the take-home message for this study?

Dr. Bally: When making a choice to treat occasional pain, fever, or inflammation, people may want to consider all available treatment alternatives as the increased risk of heart attack associated with NSAIDs may begin in the first seven days of treatment. People should read the label of NSAID medications and should use the lowest possible effective dose.

People taking these drugs for a chronic painful condition may want to consider whether the benefit of increasing the dose for better relief outweighs a possible increased risk of heart attack.

About Dr. Bally: Michèle Bally, BPharm, MSc, PhD, is an epidemiologist and researcher at the Centre Hospitalier de l’Université de Montréal (CHUM) Research Center, in Montreal, Quebec, Canada. She was an epidemiology doctoral student at McGill University, in Montreal, when she began this study.

This article was adapted from material provided by CHUM.