Clinical Edge

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Risk of Acute Myocardial Infarction with NSAIDs

BMJ; ePub 2017 May 9; Bally, Dendukuri, et al

The use of all nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen, is associated with an increased risk of acute myocardial infarction (MI), and this risk is greatest during the first month of NSAID use and with higher doses, a recent study found. The bayesian meta-analysis of individual patient data from Canadian and European healthcare database which characterized the determinants, time course, and risk of acute MI associated with use of NSAIDs. Researchers found:

  • A cohort of 446,763 including 61,460 with acute MI were identified.
  • Taking any dose NSAIDs for 1 week, 1 month, or more than a month was associated with an increased risk of MI.
  • With use of 1-7 days, the probability of increased MI risk was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib.
  • Corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib.
  • Higher dose of NSAIDs corresponded with greater risk of MI.
  • Use for longer than 1 month did not appear to exceed risks associated with shorter durations.

Citation:

Bally M, Dendukuri N, Rich B, et al. Risk of acute myocardial infarction with NSAIDs in real world use: Bayesian meta-analysis of individual patient data. [Published online ahead of print May 9, 2017]. BMJ. doi:10.1136/bmj.j1909.

Commentary:

We have known for some time that NSAIDs can increase the risk of cardiac disease. The PRECISION trial showed that moderate dose celecoxib was noninferior to ibuprofen and naproxen on a primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke in patients with arthritis at moderate cardiovascular risk. This real-world study shows an increased risk of NSAID use over a remarkably short period of 1-7 days. Pain management has become much more complex over the past few years, as the opioid epidemic requiring us to be more aware than ever before of the potential for abuse and harm with opioids. And now the addition of this data that suggests increased CV risk with even short-term use of NSAIDs makes pain management more complex. —Neil Skolnik, MD