NSAIDs and congestive cardiac failure

• there is evidence that people with heart failure who took NSAIDs were at substantially greater risk of death or being admitted to hospital for treatment of heart failure or MI, than non-users
  • risk was greater with higher doses, and diclofenac was associated with a particularly high risk
• Danish observational study examined the use of NSAIDs in patients with heart failure
  • diclofenac use was associated with an increased risk of death from all causes, greatest at doses more than 100mg/day
    • also associated with an increased risk of re-admission for heart failure and, at doses greater than 100mg/day, admission for myocardial infarction (MI)
  • celecoxib was associated with an increased risk of death, plus an increased risk of re-admission for heart failure and admission for MI
    • risk was greater at higher doses
  • ibuprofen
    • at doses of 1200mg/day or less, ibuprofen did not statistically significantly increase the risk of death, but it did at higher doses
    • at all doses, ibuprofen increased the risk of re-admission for heart failure and admission for MI
  • naproxen
    • not associated with a statistically significantly increased risk of death when used at doses of 500mg/day or less, but it did increase the risk at higher doses
    • was not associated with a statistically significantly increased risk of re-admission for heart failure
    • daily doses of naproxen at 500mg or less were associated with an increased risk of admission for MI, but at higher doses the observed increased risk was not statistically significant
• a review suggests that health professionals should consider the cardiovascular (CV) risk of NSAIDs and use them only when essential in people with heart failure (2)
  • all NSAIDs are contraindicated in people with severe heart failure
  • if an NSAID is essential, these data indicate the first choice drug is ibuprofen at 1200mg/day or less, with naproxen probably second choice at daily doses of 500mg/day or less if possible
  • co-prescription with a PPI to manage gastrointestinal side effects and guard against ulceration may also be indicated

Reference:

• 1. Gislason G, et al. Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med 2009;169:141-9
• 2. MeReC Monthly 2009; 14