SHORT- AND LONG-TERM TREATMENT WITH NON-STEROIDAL ANTI-INFLAMMATORY DRUGS INCREASES RISK OF DEATH OR RECURRENT MI IN THOSE WITH PREVIOUS MI

Context

Non-steroidal anti-inflammatory drugs (NSAIDs) have been implicated in causing negative cardiovascular outcomes, particularly in coronary artery disease (CAD) patients who have had a prior myocardial infarction (MI). In fact, as Schjerning Olsen and colleagues point out, current guidelines give the rather nebulous recommendation that duration of NSAID therapy should be as short as possible in CAD patients.1 The study by Schjerning Olsen and colleagues seeks to characterise the association between NSAID treatment duration and risk of cardiovascular disease.

Methods

Death and/or recurrent MI associated with NSAID use in patients admitted from 1997 to 2006 with first-time MI are studied in this retrospective registry analysis. The authors draw their patient population from the Danish National Patient Registry. They also utilise the Danish Registry of Medicinal Product Statistics

Findings

Of 83 677 patients, 42% received NSAIDs and 35 257 died or had recurrent MI. Overall, NSAIDs were associated with increased risk of death at the beginning of treatment (HR 1.45) and after 90 days (HR 1.55). celecoxib was associated with an increased risk of death after a treatment duration of 14–30 days. Diclofenac, however, was associated with increased risk throughout its treatment course. Naproxen was not signifi cantly associated with an increased risk of death or MI in the short term (though all HRs were >1), but it was significantly associated with death and recurrent MI when used for >90 days.

Commentary/Recommendation

This study demonstrates the potential risk of even short-term NSAID use in patients with coronary disease. This unfortunately leaves clinicians with few therapeutic options when dealing with an ageing population with musculoskeletal symptoms which are not adequately managed by acetaminophen, aspirin or narcotic analgesics. Naproxen appears to be a potentially safer alternative with regards to death and cardiovascular events in the short term, but clinicians may remain hesitant to use this drug in their CAD patients because of an elevated risk of gastrointestinal bleeding.5 the extent of over-the-counter useof NSAIDs was not captured in this registry. These limitations could be overcome in randomised clinical trials. Until such studies are conducted, limiting NSAID use in CAD patients to an ‘absolute minimum’, as the authors suggest, is certainly a pragmatic approach.

References

Anjan K Chakrabarti, C Michael Gibson Commentary on: Schjerning Olsen AM, Fosbøl EL, Lindhardsen J, et al. Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction: a nationwide cohort study. Circulation 2011;123:2226–35. In Evidence-Based Medicine April 2012 | volume 17 | number 2 |

Excerpt from: evidence based medicine journal