NSAID use in patients who have an increased cardiovascular risk

FitzGerald, 2017McGettigan, 2011Nissen, 2016Scheiman, 2005Spitz, 2013Trelle, 2011

All NSAIDs have some cardiovascular risk. If possible, avoid NSAIDs in people with established cardiovascular disease (eg heart failure, stroke) or who are at high risk of cardiovascular disease. Short-term use (eg for less than 5 days) of NSAIDs other than diclofenac may be appropriate for people who have increased cardiovascular risk.

All NSAIDs have a similar amount of cardiovascular risk other than diclofenac which has higher risk. Cardiovascular risk of NSAIDs also increases with higher doses and longer treatment duration. If treatment with an NSAID is necessary for patients who have increased cardiovascular risk, it may be preferable to choose an NSAID less likely to cause other adverse effects (eg gastrointestinal, renal)Bally, 2017Nissen, 2016.

If NSAID use is likely to be long-term, provide additional encouragement for patients to address lifestyle risk factors for cardiovascular disease (see Overview of modifiable lifestyle risk factors for atherosclerotic cardiovascular disease). In patients taking NSAIDs on an ongoing basis, cardiovascular disease risk factors should be closely monitored and actively managed.

Low-dose aspirin may reduce the increased cardiovascular risk associated with NSAIDs, but it increases the risk of gastrointestinal adverse effects. Advise patients who are prescribed low-dose aspirin for secondary prevention of vascular events to continue it regardless of their use of other NSAIDs.

Some NSAIDs (such as naproxen) have been shown to compete with the cyclo-oxygenase (COX) binding site of aspirin, reducing its efficacyGladding, 2008. Practitioners should be aware of this interaction when considering using an NSAID in a patient already taking aspirin.