Action Points
- The cardiovascular risk after the first myocardial
infarction typically declines rapidly during the first year.
- Note however that this study shows that the use of NSAIDs
is associated with persistently increased coronary risk regardless of time
elapsed after first-time MI.
The use
of nonsteroidal anti-inflammatory drugs (NSAIDs) may confer a long-term risk of
adverse cardiovascular events, a Danish population study found.
Of the
nearly 100,000 patients with first-time myocardial infarction (MI) included in
the analysis, those taking NSAIDs had a "persistent" increased risk
of all-cause death at 1 year (HR 1.59, 95% CI 1.49 to 1.69) and at 5 years (HR
1.63, 95% CI 1.52 to 1.74), according to Anne-Marie Olsen, MD, a research
fellow at Copenhagen University Hospital Gentofte in Hellerup, Denmark, and
colleagues. In
addition, those taking these anti-inflammatory drugs had a 41% increased risk
of a second MI and a 30% increased risk of coronary death during the 5-year
follow-up, they reported online in.
While
epidemiological studies such as this cannot establish causality, they said
their results are further evidence of an association between COX-2 inhibitors
and severe adverse cardiovascular events. "We
advise long-term caution in using NSAIDs for patients after MI," they
concluded. They also suggested that the availability of over-the-counter
nonselective NSAIDS such as diclofenac and ibuprofen "should be
reconsidered." Although
taking any NSAID increased the risk compared with taking none, use of
diclofenac was associated with the highest risk, they pointed out. Other
NSAIDs evaluated in this study were rofecoxib (Vioxx), celecoxib (Celebrex),
naproxen (Aleve, among other brand names), and others. At the
time of the study, only ibuprofen (200 mg) was available over the counter in Denmark.
Despite
a focused update in 2007 from the American Heart Association cautioning against
the use of NSAIDs for those with cardiovascular disease, many still receive
these drugs, although for shorter periods (Circulation
2007; 115: 1634-1642), Olsen and colleagues wrote. Because
the long-term effects of NSAIDs among those with a first MI were unclear,
researchers analyzed data from 99,187 patients in the Danish National Patient
Registry from 1997 to 2009. There
were more men (64%) than women in the study, the mean age was 69, and 44% had
filled at least one prescription of NSAIDs. Researchers
found that the overall adverse risks associated with NSAIDs "remained
virtually unchanged throughout all 5 years after discharge from hospital after
the first MI." This is
in contrast to the typical risk of cardiovascular mortality and morbidity
following an MI, which declines as time passes, Olsen and colleagues noted.
However,
rofecoxib and diclofenac conferred a greater risk of death and the composite of
recurrent MI and coronary death over time compared with other NSAIDs,
especially naproxen, which had the lowest risk. Although
it might be preferable to prescribe naproxen, researchers noted that the drug
was associated with a higher risk of gastrointestinal bleeding than rofecoxib. They
also found that those not taking anti-inflammatory drugs had a decreased risk
of adverse events over the 5 years following the index MI.The
study has several limitations, the authors noted, including its observational
nature, some missing clinical data, no data on the use of over-the-counter
aspirin, and no way to determine if patients adhered to their prescription.
However,
a strength of the study is that these data are from one country and are known
to be accurate, they said.
They
concluded that their findings support previous results that suggest there is
"no apparent safe treatment window" for NSAIDs among patients with
MI.
POSTED BY: Steven Almany M.D
