Non Steroidal Anti-Inflammatory Drug (NSAID) Use and Heart Attacks

Most of us weekend warriors are used to reaching for the ibuprofen , naproxen or aspirin for relief from aches and pains after some strenuous gardening, yard work or recreational exercise. It helps alleviate the pains and allows one to go on with their life and perform the normal activities of daily living.

For many individuals with advanced osteoarthritis or the more severe types of immunological arthritis such as rheumatoid arthritis or psoriatic arthritis, these medicines are liberating and allow patients to live a normal life. For many years the major concern with these medications was their effect on the stomach causing irritation, inflammation and gastrointestinal bleeding. Then experts issued warnings about long term use and liver and kidney damage.  These side effects were listed on the product insert and were not unexpected.

What was unexpected was the association of NSAID’s and acute heart attacks. Drugs like Vioxx and Bextra, which were extraordinarily effective at relieving aches and pains, were pulled from the market after being determined to dramatically increase the number of acute myocardial infarctions users suffered. The NSAID’s reduced joint pain and inflammation by inhibiting chemicals called prostaglandins. Unfortunately the same inhibition of prostaglandins that produced less inflammation and joint pain also inhibited prostaglandins that kept our coronary arteries from going into spasm and cutting off the circulation to our heart muscle. For several years now pharmaceutical manufacturers have been looking for the perfect formula that inhibits joint inflammation without increasing heart attack risks.

A recent study from Denmark indicated that their search has not yet been successful. Denmark maintains detailed records of patient hospital admissions and medication usage as well as a central national death registry.  Using these data bases, the records of 84,000 patients admitted to a hospital for treatment of a myocardial infarction from 1997-2006 were reviewed and linked to pharmacy records. Researchers found that 43.3% of the MI patients received NSAID’s post MI and there were 35,257 deaths or repeat heart attacks.

“Overall NSAID treatment was related to a significantly increased risk of death at the beginning of the treatment and the risk persisted throughout the treatment. Patients taking Celebrex had an increased risk of death when the treatment lasted two weeks to a month.  All NSAID’s increased the risk of death or recurrent MI by 45% after a week.  Naproxen increased the risk of death or recurrent MI by 76% after a week. For treatment lasting 30-90 days the increased risk was 15%.  Ibuprofen had the lowest initial risk, just 4% increase for treatments lasting seven days or less.

In practical terms, we must limit NSAID use to the absolute minimum in patients with established cardiovascular disease.  Based on this article, ibuprofen seems to be the best choice for short term use in patients with known cardiovascular disease. Patients with cardiovascular disease and known previous MI should be talking to their doctor before they reach for the over-the-counter bottle of a NSAID.

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Reducing Triglyceride Levels

The American Heart Association along with Michael Miller, M.D., director for the Center for Preventive Cardiology at the University of Maryland – School of Medicine in Baltimore, just released data and recommendations that diet and lifestyle changes alone should be sufficient to reduce elevated triglyceride levels.

The researchers analyzed more than 500 international studies conducted over the last 30 years for the purpose of updating doctors on the role of triglycerides in the evaluation and management of cardiovascular disease risks. The study confirmed that triglycerides are not directly atherogenic but are instead a marker of cardiovascular disease risk.  High triglycerides are commonly seen in diabetes mellitus, chronic kidney disease and certain disorders associated with HIV disease. Alcohol and obesity plus inactivity all contribute to elevated levels with TG levels rising markedly in this country since the mid 1970’s in concert with the obesity epidemic we are now seeing.

Triglycerides are checked on a fasting blood test of optimally 12 hours with the upper limit of normal set at 150mg/dl. Newer recommendations will reduce the level to 100 mg/dl.  If your triglycerides are elevated the study made the following suggestions to lower them to appropriate levels:

  1. Limit your sugar intake to less than 5% of calories consumed with no more than 100 calories per day from sugar for women and no more than 150 calories per day from sugar for men.
  2. Limit Fructose from naturally occurring foods and processed foods to less than 50 -100 grams per day
  3. Limit saturated fats to less than 7% of total calories
  4. Limit trans-fat to less than 1% of total calories.

Elevated triglycerides, especially above 500 mg/dl, are associated with an increased risk of pancreatitis. For individuals with TG levels this high we recommend complete abstinence from alcohol.

Exercise is necessary to lose weight and lower triglyceride levels as well. Physical activity of a moderate level such as brisk walking for at least 150 minutes per week (2.5 hours) can lower your triglycerides another 20-30%.

If lifestyle changes including diet modifications and aggressive exercise do not bring you to target levels we suggest the addition of marine based omega 3 products. Also, eat fleshy cold water fish!

A combination of dietary changes, moderate regular exercise and weight reduction is all that is needed to control most problems with triglycerides.  Referrals to registered dietitians can be very helpful in assisting you with the dietary changes required to be successful.