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  • Title: [Risk of fatal/non-fatal events in patients with previous coronary heart disease/acute myocardial infarction and treatment with non-steroidal anti-inflammatory drugs].
    Author: Muñoz Olmo L, Juan Armas J, Gomariz García JJ.
    Journal: Semergen; 2018; 44(5):355-363. PubMed ID: 28882733.
    Abstract:
    BACKGROUND: Primary Care is the fundamental axis of our health system and obliges us to be consistent with our prescriptions. The non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with increased cardiovascular risk and increased risk of all causes of death, as well as acute myocardial infarction (AMI) in patients with a previous myocardial infarction. Pain and cardiac patient management are 2 basic pillars in our daily activity, and we must know the limitations of NSAIDs in patients with established cardiovascular risk. OBJECTIVES: We present a review of the scientific literature with primary interest in the role of NSAIDs and cardiovascular risk. The objective is to determine the relationship between the consumption of different NSAIDs and the fatal and non-fatal events among patients with known coronary disease. METHOD: This is a review of the scientific literature with primary interest in the role of NSAIDs and cardiovascular risk. The literature review was conducted in PubMed search engines like Tripdatabase and with certain keywords. Of the 15 original papers found, 9 did not correspond completely to the central focus, so the approach was decided from 6 original articles from the past 5 years, which address the central focus of increased cardiovascular risk found (fatal and non-fatal events) in patients with prior cardiovascular disease or AMI being prescribed NSAIDs for any reason. The risk of fatal/non-fatal events in each of the studies is expressed by the odds ratio (OR)/hazard ratio (HR), defined as the probability of an event occurring. RESULTS: A moderate risk was observed for ibuprofen. It increases the risk of acute coronary syndrome after 5 years of cardiovascular event, especially in the 2nd year (OR 1.63; 95% CI 1.42-1.87). It also increases the risk of stroke (HR 1.23; 95% IC 1.10-1.38). Cyclo-oxygenase-2 inhibitors were the third risk group, after nabumetone and diclofenac. Celecoxib increases risk from the 14th day of treatment (HR 2.3; 95% CI 1.79-3.02), having an OR of 1.47 (95% CI 1.05-2.07) for new AMI. Rofecoxib shows a risk of fatal cardiovascular events, even at low doses, and after 7 days of treatment (HR 2.5; 95% CI 1.91-3.46), with an OR of 2.30 (95% CI 1.76-2.99) for new AMI. Naproxen had a lower risk of cardiovascular death and new cardiovascular events, but no significant results except for treatment longer than 90 days (HR 1.55; 95% CI 1.10-2.17), with increased gastrointestinal bleeding and associated comorbidity during the first year of treatment (HR 1.44; 95% CI 1.07-1.94). Ketorolac is seen as the drug of greatest risk for new AMI: Oral treatment (OR 3.91; 95% CI 2.02-7.58). The review highlights the cardio-protective factor of certain drugs, such as antiplatelet agents and statins in patients, with NSAIDs use. For example, in patients with greater comorbidity, differences were observed in the OR, with antiplatelet agents consumption giving an OR of 1.37 (95% CI 0.68-2.74), compared to the non-consumption, OR 1.79 (95% CI 1.16-2.78). CONCLUSIONS: The consumption of various NSAIDs and their relationship to increased risk of fatal and non-fatal acute coronary syndrome is classified by years. Consumption increases the risk regardless of the time elapsed in relation to those that did not take them, with the figures remaining virtually stable for five years. Diclofenac and cyclooxygenase-2 inhibitors (especially Rofecoxib) showed an increased risk, unlike naproxen, which had a lower risk. However, naproxen, and because of its greater capacity to generate gastrointestinal bleeding, increased for this reason, fatal events and comorbidity in these patients. Despite this, it still has the best cardiovascular safety profile.
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