Case Challenge

NSAIDs and CV Risk: The Bottom Line

Douglas S. Paauw, MD


June 23, 2017

Bottom Line on NSAIDs and CV Risk

A couple of take-home points from this case are important. First, patients with a history of cardiac disease have a 10-fold increased risk for a first-time hospitalization for HF if they are started on an NSAID. Many patients with subclinical HF may not present until an NSAID or another medication pushes them into overt HF.

The longer acting the NSAID, the bigger the risk for HF.

The second point is that the longer acting the NSAID, the bigger the risk for HF. This makes sense because NSAIDs decrease renal excretion of sodium and water. An agent that is effective in relieving pain will most likely be taken for a longer period of time, exerting this renal effect over that longer time frame. Therefore, a drug like piroxicam, which is intended for longer-term use, presents a higher CV risk than short-term use of ibuprofen.

The CV risk associated with NSAIDs is real and must be considered with all patients. The US Food and Drug Administration helpfully sent us all a letter in July 2015 to remind us of this fact.[7]

The risk conveyed by NSAIDs warrants a discussion that will help to quantify each patient's unique risk-benefit profile. However, that determination can only be made if we know that patients are using these drugs. Since they are available over the counter and widely perceived to be safe, most patients probably won't indicate that they are taking NSAIDs unless we specifically ask. And asking that important question is particularly necessary for patients with CV disease.


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