If Your Patient Has Had an MI, Do Not Give an NSAID
Abstract & commentary
By Joseph E. Scherger, MD, MPH, Clinical Professor, University of California, San Diego, CA. Dr. Scherger reports no financial relationships relevant to this field of study.
Synopsis: A large cohort study in Denmark showed that patients with a previous myocardial infarction (MI) who took any NSAID had an increased risk of death or a recurrent MI. The greater the use of an NSAID, the greater the risk.
Source: Schjerning Olsen AM, et al. Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction: A national cohort study. Circulation 2011;123:2226-2235.
A team in denmark looked at 102,138 patients who were admitted with a first myocardial infarction (MI) from 1997 to 2006. A total of 83,677 (81.9%) were discharged alive from the hospital and were included in this study. The average age was 68 with a range of 55 to 81 years old and 63% were men. At least one prescription for a nonsteroidal anti-inflammatory drug (NSAID) was identified for 35,405 (42.3%) patients. The most commonly used NSAIDs were ibuprofen, diclofenac, and naproxen. The Cox-2 inhibitors celecoxib and rofecoxib also were included in the study. The risk of each drug, time of use, and quality of use were measured.
Deaths from any cause and recurrent MI were measured in all patients. During an observation period of 14 years, 35,257 (42.1%) of the patients died or had a recurrent MI. Overall, the use of NSAIDs was significantly associated with an increased risk of death or recurrent MI with a hazard (risk) ratio of 1.55 (confidence interval, 1.29-1.62). While the greatest risk is in the first 6 months after MI, the risk steadily persisted throughout the study period. Ibuprofen, naproxen, diclofenac, celecoxib, and rofecoxib were studied separately and show similar risk. The risk was greatest with diclofenac, especially in the first 7 days after MI, with a risk ratio of 3.26.
The authors conclude that even short-term treatment with most NSAIDs is associated with increased risk of death and recurrent MI in patients with prior MI. Neither short- nor long-term treatment with NSAIDs is advised in this population, and any NSAID use should be limited from a cardiovascular safety point of view.
The Scandinavian countries have an amazing ability to do large population studies. They have well-organized patient registries that cover the entire population and substantial health information that is searchable, allowing for a tracing of health indicators over time.
This well-organized study was able to track more than 80,000 patients with an MI over 14 years and look at use of NSAIDs. The bottom line is that they are risky and lead to death or recurrent MI. This risk includes the Cox-2 inhibitors.
We all have patients in cardiac rehabilitation working out on treadmills or doing other exercise. They get muscle soreness and arthritic pain. What harm could come with using a little ibuprofen or naproxen? Plenty. Hazard (risk) ratios of < 2 for unusual events make the likelihood of death or an MI small, but why take this risk? Stretching, ice, acetaminophen, and just bearing with the discomfort are healthier alternatives. We are a population of pill poppers and one of our roles is to help our patients stay off them when the need is modest and the risk is serious.
We make our risk-benefit decisions with our patients and this study is an important contribution to those deliberations. Does this study have implications for other cardiac patients beyond those with a previous MI? As the authors point out, NSAIDs have a contraindication in all patients with cardiac disease.1,2 This study changes my practice and will make me much less likely to consider any NSAID in post-MI and other cardiac patients. Avoiding them is a rule we and our patients can live by.
1. Gislason GH, et al. Increased mortality and cardiovascular morbidity associated with the use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med 2009;169:141-149.
2. Johnsen SP, et al. Risk of hospitalization for myocardial infarction among users of rofecoxib, celecoxib, and other NSAIDs: A population-based case-control study. Arch Intern Med 2005;165:978-984.