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Nonsteroidal Anti-Inflammatory Drug Use in Patients with Heart Failure

Compelling evidence for avoiding NSAIDs underscores the challenges of pain management in these patients.

Current practice guidelines for heart failure therapy recommend avoiding non-steroidal anti-inflammatory drugs (NSAIDs), because they can cause sodium retention and vasoconstriction and can reduce the effectiveness and increase the toxicity of ACE inhibitors and diuretics. Recent findings also suggest higher risks for cardiovascular events with NSAIDs, including COX-2 inhibitors (JW Cardiol Nov 19 2008). To assess the frequency of NSAID prescription in patients with heart failure and the relation between NSAID use and outcomes, these investigators studied a Danish national cohort of 107,092 patients hospitalized from 1995 through 2004 and discharged with a diagnosis of heart failure.

More than one third (33.9%) of participants received at least one prescription for a nonselective or COX-2–selective NSAID after their hospitalizations. Median treatment duration ranged from 42 to 97 days, depending on the agent prescribed. After adjustment for measured confounders, the risks for death, hospitalization for MI, and hospitalization for heart failure were significantly elevated with any use of any NSAID. For each agent, the risk for death increased with the dose used and was independent of patients’ baseline risks for death. In unadjusted analyses, the numbers needed to treat to cause one additional death ranged from 9 (with rofecoxib) to 53 (with ibuprofen).

Comment: Although the study’s observational design renders these findings susceptible to unmeasured confounding, they strongly support current guideline recommendations to avoid NSAIDs in patients with heart failure and provide perspective on the possible magnitude of the associated risk. The results also show that the use of NSAIDs in these patients is widespread (presuming practice patterns in Denmark are similar to those elsewhere), presenting a target for quality improvement efforts. Still, a recommendation to avoid NSAIDs is easy to make but limits considerably the available strategies to alleviate pain in patients with heart failure. In some cases, patients and physicians will find themselves between a rock and a hard place.

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology February 4, 2009

Citation(s):

Gislason GH et al. Increased mortality and cardiovascular morbidity associated with the use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med 2009 Jan 26; 169:141.

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