June 10, 2019
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used drugs worldwide. These agents have been associated with higher risk of acute myocardial infarction, stroke, heart failure, and renal failure.1-2 NSAID use appears to increase left ventricular end-diastolic and systolic dimensions, raises blood pressure, and attenuates the effect of diuretics and other antihypertensive drugs.3-4 Aspirin is also a NSAID. Although these agents are associated with decompensated heart failure in patients with diagnosed heart failure, it is not known whether these agents induce incident heart failure.
A retrospective analysis of 6,769 participants enrolled in the Multi-Ethnic Study of Atherosclerosis found that the use of NSAIDs and aspirin together increased the risk of incident heart failure between 1.6 to 2-fold higher. Three models were analyzed based on adjustments for demographics, lifestyle, CVD risk factors, LV mass and NT pro-BNP determinations.5 Four groups were analyzed: no ASA or NSAID, ASA only, NSAID only, both ASA and NSAID. Patients enrolled were between the ages of 45-84, free of baseline clinical cardiovascular disease, and with extensive data on risk factors, medication use, cardiac MRI and biomarker data over 10 years of follow-up. The participants mean age was 62 years, 47% were male, and 61% were non-white. Approximately 20% used ASA, 18.3% NSAIDs, and 5.2% used both. This study was presented in abstract form at the American Heart Association Scientific Session in November, 2018.
This study adds to the growing literature of NSAID-induced cardiovascular agents, but adds that NSAIDs should be used with caution in patients taking aspirin or visa-versa. In general, NSAID-induced adverse events usually occur early in treatment, are associated with higher doses, and increase with duration of treatment.4 Clinicians have no direct treatment options for these cardio-renal complications other than to advise against use, reduce the duration of use, or recommend an alternate pain management agent.4, 6 There remains a critical need to develop a treatment to reduce the incidence of NSAID-induced cardiovascular adverse events, especially heart failure.
Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.
- Haag MD, Bos MJ, Hofman A, et al. Cyclooxygenase selectivity of nonsteroidal anti-inflammatory drugs and risk of stroke. Arch Intern Med 2008;168:1219-24.
- Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med November 13,2016 DOI: 10.1056/NEJMoz1611593.
- van den Hondel KE, Ejgelsheim M, Ruiter R, et al. Effects of short-term NSAID use on echocardiographic parameters in elderly people: a population-based cohort study. Heart 2011;97:540-3.
- http://www.fda.gov/Drugs/DrugSafety/ucm451800.htm Accessed 06/03/2019
- Mostertz WC, Chen J, Delaney JA, Shah SJ, Yeboah J, Bertoni AG. Association of nonsteroidal anti-inflammatory drug use with incident heart failure within the multi-ethnic study of atherosclerosis. Presented at: AHA 2018; November 10-12, 2018 Chicago, Illinois, Abstract Sa1113/1113.
- Scarpignato C, Lanas A, Blandizzi C, Lems WF, Hermann M, Hunt RH, For the International NSAID Consensus Group. BMC Medicine 2015;13:55