Heart Association Warns of NSAID’s Link to Heart Disease

March 2007

In new guidelines for treatment of pain and osteoarthritis, the American Heart Association has urged doctors not to prescribe certain pain relievers for people who have heart disease or are at elevated risk of heart attack or stroke due to other health condition or lifestyle.

Specifically, the group has advised doctors to avoid prescribing non-steroidal anti-inflammatory drugs (NSAIDs) such as Celebrex, ibuprofen (Advil, Motrin and generics), naproxen (Aleve and generics), diclofenac (Cataflam), and meloxicam (Mobic) for such patients unless other measures and/or drugs to reduce pain fail to work.

The reason: these drugs increase the risk for heart attack, stroke, heart failure, and high blood pressure – though by how much is unclear. If you are taking an NSAID and also being treated for heart disease, you should consult with your doctor. There is no need to stop taking the medicine until you consult your doctor.

The AHA recommends – in an article published in the journal Circulation (March 13, 2007) – that patients with heart disease or risks be treated first with non-drug measures (such as physical therapy, ice packs, exercise, weight, or orthotics) and aspirin or acetaminophen (Tylenol). If those don’t work and the pain is acute, doctors should consider opioid-based pain relievers (those that contain narcotic drugs such as hydrocodone, codeine, propoxyphene and tramadol) before prescribing an NSAID.

Only as a last resort should an NSAID be prescribed in this patient population, with naproxen (Aleve) the preferred choice. The population in question include:

• All people with high blood pressure, high cholesterol, or diabetes
• All who have had a heart attack or stroke, or have peripheral artery disease
• All who have undergone surgery to treat artery blockages
• All who smoke, are overweight, and/or do not exercise, or have a family history of early heart disease

Thus, the recommendations apply to over 80 million people in the U.S.

The group also recommends that doctors try treating all people with mild to moderate chronic pain – whether they have heart disease or not – with non-drug measures first. If those don’t work, aspirin or acetaminophen should be tried next, before the NSAID naproxen.

Aspirin is the only pain reliever that has been associated with a lower risk of heart attack and stroke in both people at high risk and low risk for heart attack and stroke. Studies have found that aspirin lowers the risk of heart attack and stroke by up to 30% in people who have heart disease risk factors. It also carries its own risks, however, of stomach bleeding and, more rarely, brain hemorrhage.

You should not take aspirin everyday for long periods either as a pain reliever or a heart disease preventive without consulting a doctor to gauge your risks and assess your overall medical status.

The AHA underscored that when any drug is prescribed for pain, including aspirin and acetaminophen, the lowest dose should be used for the shortest duration possible.

These guidelines contrast quite sharply with medical practice in recent years. The NSAIDs have been and remain widely prescribed. The AHA’s statement is the most pointed and strongest to date suggesting that doctors migrate away from the routine use of these drugs.

The AHA’s recommendations are largely consistent with those we make in the report on NSAIDs on this Web site. You can click here to go to that report, which gives further background and recommendations on the use of the NSAIDs.