How Safe Are NSAIDs for Someone Who Has Had a Heart Attack?

Q: I have osteoarthritis and need to take something for pain relief. How safe are non-steroidal medications for someone who has had a heart attack?

A: In this era of growing concern over opioids, individuals with osteoarthritis (OA) and rheumatoid arthritis (RA) commonly use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.

After the NSAID rofecoxib (Vioxx) was found to increase the risk of heart attack and stroke, adverse cardiovascular (CV) events from other NSAIDs have remained a concern. Clinical studies suggest NSAIDs may, indeed, increase CV events. However, this risk varies and should be assessed relative to the value of pain control.

The PRECISION trial demonstrated that celecoxib (Celebrex®) at recommended doses was not associated with an increased rate of CV events, compared with maximum titrated doses of over-the-counter naproxen (Aleve®) and ibuprofen (Advil®, Motrin®).

A subsequent analysis found that gastrointestinal, kidney and other side effects were 20% more common with naproxen and 38% more common with ibuprofen than celecoxib. NSAID toxicities were not significantly different by age, sex, type of arthritis, tobacco use or history of ulcers, but were higher among patients with diabetes and those who were not taking aspirin.

OA patients appeared to respond equally to all three types of pain relievers, while RA patients responded slightly better to ibuprofen. Although no comparison was made to placebo, the overall message was that all three drugs can help improve quality of life in arthritis patients with reasonable safety.

Starting with a 100- to 200-mg dose of celecoxib may be the safest choice in patients with CV disease. If celecoxib does not produce adequate pain relief, naproxen or ibuprofen should be considered.

Choosing a medication based on your medical history and risk factors, while continuing low-dose aspirin and, possibly, a proton pump inhibitor may minimize your risks when pain control is necessary.

— Interventional cardiologist Leslie Cho, MD