Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction A Nationwide Cohort Study

Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark.
Circulation (Impact Factor: 14.43). 05/2011; 123(20):2226-35. DOI: 10.1161/CIRCULATIONAHA.110.004671
Source: PubMed


Despite the fact that nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated among patients with established cardiovascular disease, many receive NSAID treatment for a short period of time. However, little is known about the association between NSAID treatment duration and risk of cardiovascular disease. We therefore studied the duration of NSAID treatment and cardiovascular risk in a nationwide cohort of patients with prior myocardial infarction (MI).
Patients ≥30 years of age who were admitted with first-time MI during 1997 to 2006 and their subsequent NSAID use were identified by individual-level linkage of nationwide registries of hospitalization and drug dispensing from pharmacies in Denmark. Risk of death and recurrent MI according to duration of NSAID treatment was analyzed by multivariable time-stratified Cox proportional-hazard models and by incidence rates per 1000 person-years. Of the 83 677 patients included, 42.3% received NSAIDs during follow-up. There were 35 257 deaths/recurrent MIs. Overall, NSAID treatment was significantly associated with an increased risk of death/recurrent MI (hazard ratio, 1.45; 95% confidence interval, 1.29 to 1.62) at the beginning of the treatment, and the risk persisted throughout the treatment course (hazard ratio, 1.55; 95% confidence interval, 1.46 to 1.64 after 90 days). Analyses of individual NSAIDs showed that the traditional NSAID diclofenac was associated with the highest risk (hazard ratio, 3.26; 95% confidence interval, 2.57 to 3.86 for death/MI at day 1 to 7 of treatment).
Even short-term treatment with most NSAIDs was associated with increased risk of death and recurrent MI in patients with prior MI. Neither short- nor long-term treatment with NSAIDs is advised in this population, and any NSAID use should be limited from a cardiovascular safety point of view.

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Available from: Gunnar Gislason
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    • "Furthermore, there is increasing evidence that all NSAIDs, not only COX-2 inhibitors, are associated with an increased risk of cardiovascular events and should, therefore, be used with caution.19 In patients with prior myocardial infarction, even short-term treatment with most NSAIDs has been shown to be associated with an increased risk of death and recurrence, and neither short- nor long-term NSAID treatment is advised in this population.19 If osteo-articular pain is not relieved by paracetamol or other non-opioid analgesics, weak and strong opioids should be considered as treatment options.20 "
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    ABSTRACT: Pain is a common symptom in orthopedic patients, but is managed sub-optimally, partly due to scarce opioid use in severe cases. The aim of the Orthopedic Instant Pain Survey (POIS) was to evaluate changes in pain management in Italian orthopedic practice 2 years after a legislative change (Law 38/2010) simplifying opioid access for pain control. A web-based survey on the knowledge of this law and trends observed in clinical practice for severe pain treatment was administered to 143 Italian orthopedic specialists. In total, 101 (70%) respondents showed a high level of knowledge. Nevertheless, 54.5% stated that they do not use opioids for severe osteo-articular pain management. Main barriers to opioid use are fear of adverse events (61.4%), especially nausea/vomiting and constipation, and patient resistance (29.7%). A modest knowledge of pain classification was also demonstrated. Opioid use remains very limited in Italian orthopedic practice. Physicians' fear of side effects showed poor knowledge of strategies for effective management of opioid-related adverse events, such as combined oral prolonged-release oxycodone/naloxone. Continuing educational programs could improve delivery of evidence-based pain management.
    Full-text · Article · Apr 2014 · Orthopedic Reviews
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    • "A recently published retrospective database study raised concern of NSAIDs as a whole being associated with increased deaths and recurrent MIs in a population with previous MI (not a surgical population) [20]. Interestingly the authors found that ibuprofen usage below 7 days, was not associated with increased death and MI [20]. It can be speculated that the lower incidence of thromboembolic complications in the multimodal group in our study, was due to the antithrombotic effect of the NSAIDs [21]. "
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    ABSTRACT: To evaluate if an opiate sparing multimodal regimen of dexamethasone, gabapentin, ibuprofen and paracetamol had better analgesic effect, less side effects and was safe compared to a traditional morphine and paracetamol regimen after cardiac surgery. Open-label, prospective randomized controlled trial. 180 patients undergoing cardiac procedures through median sternotomy, were included in the period march 2007- August 2009. 151 patients were available for analysis. Pain was assessed with the 11-numeric rating scale (11-NRS). Patients in the multimodal group demonstrated significantly lower average pain scores from the day of surgery throughout the third postoperative day. Extensive nausea and vomiting, was found in no patient in the multimodal group but in 13 patients in the morphine group, p < 0.001. Postoperative rise in individual creatinine levels demonstrated a non-significant rise in the multimodal group, 33.0+/-53.4 vs. 19.9+/-48.5, p = 0.133. Patients in the multimodal group suffered less major in-hospital events in crude numbers: myocardial infarction (MI) (1 vs. 2, p = 0.54), stroke (0 vs. 3, p = 0.075), dialysis (1 vs. 2, p = 0.54), and gastrointestinal (GI) bleeding (0 vs. 1, p = 0.31). 30-day mortality was 1 vs. 2, p = 0.54. In patients undergoing cardiac surgery, a multimodal regimen offered significantly better analgesia than a traditional opiate regimen. Nausea and vomiting complaints were significantly reduced. No safety issues were observed with the multimodal regimen.Trial registration: identifier: NCT01966172.
    Full-text · Article · Mar 2014 · Journal of Cardiothoracic Surgery
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    • "Conversely, the lack of an immediate, dramatic adverse reaction to a treatment may create the impression that it's safer than the evidence indicates. For example, despite non-steroidal anti-inflammatory drugs being significantly associated with an increased risk of death and recurrent myocardial infarction when used by people with cardiovascular disease, they are still widely used, advertised and prescribed for this population possibly because the adverse outcomes are not immediate or obvious [4]. Finally, Ropiek suggests that a large perception gap can lead to social policies which don't maximise public health or spending but instead aim to assuage feelings of fear. "
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    ABSTRACT: We are living with risks all the time; it's just a fact of life. There are some risks we happily accept, others we fear so much that they over-ride our rational decision making and some very large risks that are so mundane that we often ignore them. Identifying, minimising and communicating risk is necessary for improving public safety and a frequent concern for many working in healthcare. However, there is relatively little discussion about risk perception, which ultimately influences how people respond and can explain why some make seemingly irrational decisions, regardless of the evidence. This has obvious implications for clinicians and patients, but also committees and policy makers who consist of individuals with varying levels of experience, knowledge and risk perception. Deciding to restrict or promote a particular behaviour, access to a medicine, practice of a profession or integration of a therapy will be influenced by these factors. This article reviews some of the social science and psychology literature which has identified the key factors which attenuate or amplify risk perception. In particular, Ropeik's perception gap is discussed together with Slovic's work identifying factors which affect risk perception and heuristics. Several examples are given which are relevant to integrative medicine as it relates to safety. Drug–herb interactions and the perceived danger of herbal and nutritional medicines in surgery are key examples. The ‘risk as feelings’ hypothesis is also discussed as a means of better understanding barriers to the adoption of evidence based integrative medicine, and how it may affect practitioner–patient interactions.
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