Risks and Recommendations: The Use of NSAIDs in Patients With Cardiovascular Disease

CAD

• Avoid NSAIDs because of dose-related increase in MACE, even when used for short durations
• If NSAIDs are medically necessary, educate patients about risks
• Nonselective NSAIDs are preferable
• Use ibuprofen only as needed in patients receiving aspirin for secondary prevention
• Take ibuprofen at least 30 minutes after immediate-release aspirin or more than eight hours prior to aspirin

Heart failure

• Avoid NSAIDs when possible
• Celecoxib may be safer
• Low-dose aspirin likely safe when indicated (eg, prior MI)
• Educate patients taking nonprescription NSAIDs to use lowest doses and shortest durations possible and consult healthcare provider for significant changes in body weight to reduce decompensation risk

Hypertension

• Patients at risk for developing hypertension should be monitored for changes in BP with NSAIDs, although infrequent as-needed use is likely acceptable
• NSAID use should be evaluated concurrently with other lifestyle changes
• In preexisting hypertension, NSAIDS should be avoided
• In hypertensive patients taking NSAIDs, adjustments in hypertensive therapy and closer monitoring may be required

• Insufficient evidence to make recommendations
• Use caution in patients at high risk

• Patients at risk for UGIB should avoid NSAIDs
• Nonprescription NSAIDs should be used at lowest dose and shortest duration
• Ibuprofen, celecoxib and potentially diclofenac appear to have lowest risk
• Consider gastroprotective agents (eg, histamine-2 receptor blockers or proton pump inhibitors)

• Utilize patient-individualized multimodal analgesic regimens
• If necessary, use central regional blocks with local anesthetics, neuromodulators, and acetaminophen
• Use nonpharmacologic therapies (relaxation, imagery, acupuncture)

• FDA warns against use of NSAIDs in this setting
• Short-term use of nonselective NSAIDs (eg, naproxen, ketorolac) may be safe in select patients

• Use with caution
• Consider acetaminophen, neuromodulators, or weak opioid (eg, tramadol, codeine) if necessary 

• Consider nonpharmacologic therapies (eg, physical activity and weight loss) in all patients
• Use topical NSAIDs, acetaminophen, tramadol, intraarticular corticosteroid injections

• NSAIDs are first-line therapy
• Ibuprofen preferable and continued for several weeks, along with GI protection
• Aspirin, colchicine and/or corticosteroids may be considered

• Use aspirin as initial therapy
• Consider acetaminophen, colchicine, and/or narcotic analgesics in refractory cases
• NSAIDs and glucocorticoids may be helpful in the setting of MI