Recommendations for NSAID use in Patients with CVD


Disease

Recommendation
 

CAD


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  • 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
 Atrial fibrillation  

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

  • 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)
 Noncardiac surgery  

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

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

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

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

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

  • 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