Concomitant NSAID Treatment After MI

Jul 28, 2020
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Authors:
Kang DO, An H, Park GU, et al.
Citation:
Cardiovascular and Bleeding Risks Associated With Nonsteroidal Anti-Inflammatory Drugs After Myocardial Infarction. J Am Coll Cardiol 2020;76:518-529.
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • NSAID use is associated with higher risk of ischemic events following MI.
  • NSAID use is associated with higher risk of bleeding events following MI.
  • Avoiding NSAID use after MI may reduce bleeding and ischemic risk.

Study Questions:

What are the cardiovascular and bleeding risks associated with antithrombotic treatment and concomitant nonsteroidal anti-inflammatory drug (NSAID) use following myocardial infarction (MI)?

Methods:

The authors performed a nationwide cohort analysis of the Korean Health Insurance Review and Assessment Service database between 2009 and 2013. Patients were divided into cohorts based on their prescribed antithrombotic medications (aspirin, clopidogrel, and vitamin K antagonists). NSAIDs evaluated included prescription celecoxib, meloxicam, aceclofenac, diclofenac, naproxen, ibuprofen, dexibuprofen, and zaltoprofen. The primary outcome included thromboembolic cardiovascular events, defined as recurrent MI, ischemic stroke, transient ischemic attack, or systemic arterial embolism. The secondary outcome was clinically relevant bleeding. Hazard ratios were calculated from Cox proportional models after adjusting for NSAIDs as a time-varying covariate and for potential clinical confounders (e.g., demographics, comorbidities, and concomitant cardiovascular medications).

Results:

Among 108,232 patients (mean age 64.2 ± 12.8 years, 72.1% male) with a mean follow-up of 2.3 ± 1.8 years, concomitant NSAID use was associated with an increased risk of cardiovascular events (hazard ratio [HR], 6.96; 95% confidence interval [CI], 6.24-6.77) as well as clinically relevant bleeding (HR, 4.08; 95% CI, 3.51-4.73) as compared to no NSAID use. Among the different NSAID subtypes, the risk for cardiovascular and bleeding events was lowest for patients using celecoxib (HR, 4.65; 95% CI, 3.17-6.82 and HR, 3.44; 95% CI, 2.20-5.39) and meloxicam (HR, 3.03; 95% CI, 1.68-5.47 and HR, 2.80; 95% CI, 1.40-5.60).

Conclusions:

The authors concluded that concomitant NSAID use was associated with a significantly increased risk of both cardiovascular and bleeding events following MI.

Perspective:

Similar to prior studies, this large Korean nationwide study associates NSAID use with increased risk of cardiovascular and bleeding events. However, the degree of risk associated with NSAID use appears larger in this study than in prior Western cohort studies. Additionally, over-the-counter NSAID use was not able to be assessed in this study, meaning that many of the patients with prescription NSAIDs may have had more severe disease. Nonetheless, the association with both ischemic and bleeding events is another reminder for cardiovascular clinicians to screen for and recommend against any NSAID use whenever possible in patients with cardiovascular disease, especially shortly after MI.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Prevention, Anticoagulation Management and ACS

Keywords: Acute Coronary Syndrome, Anticoagulants, Anti-Inflammatory Agents, Non-Steroidal, Aspirin, Fibrinolytic Agents, Hemorrhage, Ibuprofen, Ischemic Attack, Transient, Myocardial Infarction, Myocardial Ischemia, Naproxen, Risk, Secondary Prevention, Thrombosis


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