Beware the use of NSAID’s after an MI

NSAID use is very common. Myocardial infarctions are very common. And the use of NSAID’s in patients with coronary artery disease is very common. But a study published last year in Circulation (May 25, 2011) offers a cautionary tale about the risks of prescribing NSAID’s to CAD patients, even for a short period.

In this observational study, the records of almost 84,000 survivors of a first MI in Denmark were examined. Medication records, which are comprehensively maintained in Denmark, showed that 42.3% of these first-time MI patients received at least one NSAID prescription subsequent to their infarct. The study looked at death and reinfarction rates, correlated with NSAID use, and found an increased risk of these complications with a hazard ratio of 1.45.

It was notable that even short term use of an NSAID, such as one to two weeks total duration of use, led to an increased risk of death and reinfarction. This increased risk occurred with use of both COX-2 inhibitors and non-selective COX agents. The only agent which did not appear to increase the risk of death or reinfarction was naproxen.

As is true in any observational study, it is hard to definitively attribute the results to a cause-and-effect relationship, i.e. stating with certainty that NSAID’s in CAD patients cause recurrent MI’s. But the numbers of patients included were impressive, and the study should at least raise a red flag over the use of NSAID’s in post-MI patients, even for a short duration of time. As the authors point out, their study raises questions about the American Heart Association’s 2007 recommendations for NSAID use in CAD patients, which only advised caution in using COX-2 inhibitors and avoiding the long-term use of non-selective NSAID’s.

So, when your CAD patient asks for an NSAID, consider alternative analgesic approaches, even if the intent is to use the medication briefly.

Thanks to Dr. Kate Colwell for suggesting a post on this study.

Richard Fleming, MD

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