Taking a common type of pain reliever may increase the risk of a second heart attack and death, a new study suggests. The study kept track of people for 5 years after a first heart attack. The higher risk applied to those who took any nonsteroidal anti-inflammatory drug (NSAID). These drugs include ibuprofen (Advil, Motrin and others) and naproxen (Aleve, Naprosyn and others). Prescription types include celecoxib (Celebrex). The study was done in Denmark. In that country, all NSAIDs except low-dose ibuprofen require a prescription. Researchers looked at records for almost 100,000 people who had a first heart attack. In the next 5 years, nearly half of them filled a prescription for an NSAID. People who took the painkillers had a 63% higher risk of death from any cause. They had a 41% higher risk of another heart attack. The results show that doctors should use caution in prescribing any NSAID after a heart attack, experts told HealthDay News. That caution applies even several years later, they said. Researchers urged U.S. officials to reconsider the current practice of allowing some NSAIDs to be sold without a prescription. The journal Circulation published the study online September 10.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Most people don't think twice about taking Motrin, Advil, Aleve or similar over-the-counter drugs. These drugs and many other others belong to a class called nonsteroidal anti-inflammatory drugs (NSAIDs). With some exceptions, they are considered pretty safe when used occasionally in low to moderate doses to relieve pain.

The exceptions include people with kidney disease and those with a history of peptic ulcer or upper gastrointestinal bleeding. They should avoid using NSAIDs. People with heart failure, advanced liver disease or high blood pressure need to check with their doctors before taking NSAIDs.

For some time, we have also known that some NSAIDs pose a higher risk of heart attack and early death. Vioxx was taken off the market for this reason. But many NSAIDs are still readily available over-the-counter and by prescription. For them, the risk of heart problems has not received much attention.

This is about to change. The results of a new study suggest thinking twice about taking any NSAID other than aspirin if you have had a heart attack. The journal Circulation published the study online.

Researchers in Denmark did the study. They were able to look at what happened to almost 100,000 people who had a first heart attack. During the next 5 years, almost one-half of them were prescribed an NSAID at least once.

Use of an NSAID increased the risk of death from any cause by 59%. The risk of a heart-related death or second heart attack increased 41%.

People who took any NSAID (again other than aspirin) had a higher risk of death or second heart attack. However, of all the NSAIDs, naproxen (Naprosyn, Aleve, and many generics) appeared to carry the lowest risk. The lower risk with naproxen confirms what has been seen in older studies.

This study was not designed to answer why the higher risks occurred among people taking NSAIDs. One theory is that people who take an NSAID might stop taking aspirin. Except for people with aspirin allergies, everyone should take low-dose aspirin for the forseeable future after a heart attack to avoid a second one.

Another possible reason is the potential for NSAIDs to block the effect of aspirin that helps to block heart attacks. Aspirin binds to platelets. This makes the platelets less sticky, which decreases blood clot formation in the arteries near the heart. Blood clots in narrowed arteries are the major cause of heart attacks.

What Changes Can I Make Now?

If you have heart disease and need pain relief, try acetaminophen first. Many generics are available and will work just as well as Tylenol. Keep the maximum dose to 3,250 milligrams per day. Doses higher than this increase the risk of liver damage.

Note that each regular-strength acetaminophen tablet or capsule contains 325 milligrams. Extra strength means 500 milligrams.

If you do need an NSAID after a heart attack, it's best to check with your doctor first. He or she will likely be okay with you using an occasional NSAID for a headache or for other pain that is likely to last for a short time.

Of the NSAIDs, naproxen is probably the best choice. But whatever you and your doctor decide is best for you, use the lowest dose possible for the shortest period of time.

If you do take an NSAID, take your aspirin first. Wait an hour to take the NSAID. This is especially true for ibuprofen. Waiting gives the aspirin enough time to bind to platelets. Then the NSAID won't be competing.

What Can I Expect Looking to the Future?

There is still much we need to understand about the effects of NSAIDs on the heart and blood vessels. This study suggests caution with all NSAIDs at any dose if you have had a heart attack. But future studies are likely to help doctors give each patient more specific advice.