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Study Tallies Painkiller Risk after Heart Attack

Howard LeWine, M.D.

Some common painkillers may increase the risk of second heart attacks when taken along with drugs to prevent clots, a large new study finds. The study adds to concerns about potential heart risks of nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are taken to reduce pain and inflammation.

They include over-the-counter medicines such as ibuprofen (Motrin, Advil) and naproxen (Naprosyn, Aleve). They also include the prescription drug celecoxib (Celebrex). The new study used data from a Danish registry of 61,971 people who survived a first heart attack. Everyone was taking at least 1 anti-clotting drug, such as aspirin or clopidogrel (Plavix). Researchers looked at what happened during an average follow-up period of 3½ years. About one-third of those in the study filled at least 1 prescription for an NSAID.

About 30% of those in the study had another heart attack or stroke, or died of heart-related causes. These events were 40% more likely to occur in those who took NSAIDs than in those who did not. The increase in risk varied depending which drugs were taken and how many. The risk of bleeding also doubled for those who took NSAIDs. The Journal of the American Medical Association published the study. HealthDay News wrote about it February 24.

What Is the Doctor’s Reaction?

We take NSAIDs so often that we forget they have the potential to be dangerous. That’s especially true after a heart attack, according to results of this study.

NSAID stands for nonsteroidal anti-inflammatory drug. These drugs include over-the-counter ibuprofen (Advil, Motrin and others) and naproxen (Aleve and others). They also include prescription drugs such as celecoxib (Celebrex).

Patients who have had a heart attack are told to take a daily aspirin to help prevent a second heart attack. Aspirin attaches to blood cells called platelets to make them less sticky. This decreases the risk of blood clots forming in heart arteries.

Sometimes, doctors also prescribe a second anti-platelet drug, such as clopidogrel (Plavix). This is standard care if you have had a procedure called angioplasty and stenting. A balloon is inflated inside an artery to open it. Then the stent, a wire mesh tube, is placed inside to keep it open. Some people may need a third so-called blood thinner if they also have an abnormal heart beat known as atrial fibrillation.

The use of any anti-platelet drug, even a baby aspirin, increases the risk of bleeding inside your body. When you add a second or third blood-thinner, the risk rises even more.

NSAIDs are well known to also increase bleeding risk. Taking one of them when you also need to take aspirin, another blood thinner or both further raises the risk. The results of this study show this combination can be especially dangerous for people who have had a heart attack. If they bleed, their chances of dying are much higher if they are taking an NSAID as well as a blood thinner.

The researchers also found that people who use NSAIDs after a heart attack are more likely to have another heart attack or stroke. This might seem odd, given that most heart attacks and strokes are caused by blood clots. After all, NSAIDs generally make it harder for blood clots to form. Taking them along with an anti-platelet drug should further reduce the risk of clots.

The exact reason for the higher chance of heart attack and stroke with NSAID use is not clear. But many other studies have found a similar link.

What Changes Can I Make Now?

Getting safe pain relief can be a challenge if you are taking an anti-platelet drug or another type of blood thinner.

Here are some ideas:

Start with a non-drug approach. Try a heating pad, ice or physical therapy, if appropriate. Even if these approaches don’t take away your pain, they may let you take a lower dose of a painkiller.

Use acetaminophen. Acetaminophen (Tylenol, generic versions) may be an alternative to an NSAID. However, you must limit your use of this drug if you have a liver problem or some other conditions. A safe amount is 3,250 milligrams per day. That’s no more than 10 regular-strength or 6 extra-strength tablets spread out over 24 hours. Acetaminophen reduces fever and pain. It does not reduce inflammation. For people with arthritis, reducing inflammation is usually important, so this option won’t work for everyone.

Consider other NSAID alternatives. Non-acetylated salicylates are cousins to aspirin. They include salsalate (Disalcid) and choline magnesium trisalicylate (Trilisate). These drugs may provide pain relief and reduce inflammation somewhat.
Use the safest NSAID. Some NSAIDs may be less risky than others. The prescription NSAID diclofenac (Voltaren) appears to have the highest risk for a second heart attack. Some studies suggest that naproxen (Aleve, Naprosyn) has the lowest risk.

Take your aspirin first. Aspirin prevents clotting that can lead to a heart attack. Some studies suggest NSAIDs may interfere with aspirin’s protective effect. So, if you have heart disease and must use an NSAID, take the aspirin first. Wait an hour. Then take your required dose of the NSAID drug.

Use only what you need. Take the lowest effective dose of an NSAID for the shortest period of time. However, in this study, even three days of use increased the chance of bleeding.

What Can I Expect Looking to the Future?

Sometimes there’s no good alternative to an NSAID for treating pain in someone who has had a heart attack. In this case, many heart specialists recommend naproxen.

Most studies suggest that naproxen is safer for the heart than other NSAIDs. But this is not proven. For now, the U.S. Food and Drug Administration requires that naproxen carry the same warning as other NSAIDs do.

Date Last Reviewed: 2/25/2015 Date Last Modified: 2/25/2015  Author: Howard LeWine, M.D.
Copyright by Harvard University. All rights reserved. Content Licensing by Belvoir Media Group

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