Pain Drugs Raise Heart Risk for Healthy

By Robert Shmerling, M.D.
Content provided by the Faculty of the Harvard Medical School

Some pain relievers may increase the risk of heart problems in healthy people, a large study finds. The study was done in Denmark. It included records on 1 million healthy people from a national database. Their average age was 39. The study focused on use of nonsteroidal anti-inflammatory drugs (NSAIDs). One prescription NSAID was taken off the U.S. market in 2004. Rofecoxib (Vioxx) was withdrawn because users had an increased risk of heart attack and stroke. The Danish study showed a higher risk of death from heart and blood vessel disease for people who used Vioxx. The risk was 66% higher than for people who took no NSAIDs. Death risk from these causes was 91% higher with diclofenac (Voltaren, Cataflam). Stroke risk rose 29% for people who took an over-the-counter drug, ibuprofen (Advil, Motrin and others). There was not a clear increase in risk with celecoxib (Celebrex) or naproxen (Aleve and others). Still, the overall risk of problems among healthy people was low, the lead author of the study told HealthDay News. The study appeared June 8 in the journal Circulation: Cardiovascular Quality and Outcomes.

What Is the Doctor's Reaction?

The benefits of non-steroidal anti-inflammatory drugs (NSAIDs) are well known. They can reduce pain and inflammation and bring down a fever. These drugs include ibuprofen (Motrin, Advil and others) and naproxen (Aleve and others).

But their risks are less clear. The most common side effect is upset stomach. Occasionally, these drugs cause stomach ulcers that may bleed or require surgery. Allergic reactions and kidney injury are other concerns.

Can they also cause heart disease? That's been a matter of some debate.

Remember Vioxx? This drug (generic name rofecoxib) was taken off the market in 2004. Studies had suggested that it increased the risk of heart attack. More recently, concern has been raised that older NSAIDs might do the same thing.

Studies looking at this issue have been mixed. Some were reassuring. Others linked NSAID use with heart attack or other blood vessel problems. The link was strongest among people who already had heart disease or a high risk of developing it.

That's why a new study is so important. It included more than a million healthy people in Denmark. Denmark has a comprehensive medical data system. It can be used to study health, medicine use and the development of medical problems over time.

Researchers looked at data for a 9-year period. Here's what they found:

  • People who took diclofenac (Voltaren, Arthrotec) had nearly twice the risk of death from heart and blood vessel disease as those not taking NSAIDs.

  • Rofecoxib use was linked with a 66% increase in the rate of death related to heart and blood vessel disease.

  • The risk of death was even higher among users who took the highest doses.

  • People taking ibuprofen had a 29% increased risk of stroke.

  • Naproxen use was not linked with an increased risk of heart disease.

  • The impact of celecoxib (Celebrex) on heart and blood vessel disease risk was not clear.

I must admit, these findings are rather worrisome. Millions of people take NSAIDs. Therefore, even a small increase in risk could affect large numbers of people. But, before we write off the use of NSAIDs forever, keep in mind some limitations of this research:

  • A study of this type cannot determine whether NSAIDs actually caused heart and blood vessel disease. For example, some people might have taken NSAIDs for symptoms (such as shoulder or neck pain) related to heart disease. As a result, use of an NSAID might appear to increase the risk of heart disease when it really didn't.

  • The overall risk of NSAID use was low. For example, about 1 in 1,000 people taking diclofenac died of heart or blood vessel disease.

  • The study did not mention certain factors (such as smoking or high blood pressure) that might have increased heart risk much more than NSAID use. It's possible that NSAID use is only risky among those with other risk factors.

  • There are more than 25 different NSAIDs. Only a few were included in this study, so it remains uncertain which is safest.

  • For some people, NSAID use is so helpful that they would accept a small increase in the risk of heart and blood vessel disease. In fact, I still have patients requesting rofecoxib because it worked so well for them.

Your Guide to Heart Disease

Did You Know?

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Pain or discomfort in the jaw, neck, or back could be a symptom of a heart attack.