‘NSAIDs after myocardial infarction raise bleeding risk’

Author: By Kim Yun-mi

Korean Biomedical Review

Using nonsteroidal anti-inflammatory drugs (NSAIDs) with antiplatelet agents in patients with acute myocardial infarction increased the risk of cardiovascular events seven times, and bleeding risk by four times, compared to NSAIDs-free treatment, a study showed.

The research team, led by Professor Choi Cheol-ung of the Cardiovascular Center at Korea University Guro Hospital, published the study, titled, “Cardiovascular and Bleeding Risks Associated With Nonsteroidal Anti-Inflammatory Drugs After Myocardial Infarction,” in the July issue of Journal of the American College of Cardiology (KACC).

The cohort study analyzed the association of NSAIDs with cardiovascular events (myocardial infarction, stroke, systemic embolism) and bleeding events (gastrointestinal bleeding, brain bleeding, respiratory bleeding, urinary bleeding) in 110,000 domestic patients admitted for a first-time heart attack between 2009 and 2013.

According to the analysis and the 2.3 years of follow-up, NSAID treatment with anti-platelet drugs increased the risk of cardiovascular events by seven-fold, and bleeding events by four times, compared with no NSAID treatment.

Among NSAIDs, celecoxib, and meloxicam, which are cyclooxygenase-2 (COX-2) inhibitors, showed relatively low cardiovascular and bleeding risks, the research team noted.

Celecoxib, in particular, had 35-40 percent lower cardiovascular risk and 15-20 percent lower bleeding risk, compared to other types of NSAIDs.

Patients with acute myocardial infarction must maintain anti-platelet medication for a lifetime. With the rapid aging, prescriptions of NSAIDs for musculoskeletal diseases are increasing. Along with this, patients increasingly need both antiplatelet and anti-inflammatory treatments to prevent secondary atherosclerotic cardiovascular disease and control symptoms of musculoskeletal disorders.

It is known that the use of anti-inflammatory drugs in patients who take anti-platelet drugs raises the chance for both cardiovascular and bleeding events. Myocardial infarction treatment guidelines recommend that patients in these groups avoid NSAIDs as much as possible.

However, existing studies have been centered on Western patients. Some physicians still had to prescribe NSAIDs to control symptoms of musculoskeletal and inflammatory diseases. Thus, the researchers had to find specific risks associated with the combination of antiplatelet and anti-inflammatory drugs and what kind of NSAIDs are relatively safe.

First author Kang Dong-oh, a professor at the Cardiovascular Center of Korea University Guro Hospital, said the study demonstrated new evidence to use COX-2 inhibitors as an alternative if NSAIDs are unavoidable in patients with acute myocardial infarction.

Also, the study accurately presented the risk level of cardiovascular and bleeding events in the use of NSAIDs, he added.

Professor Choi, the lead author, said the study was the largest cohort study in the world to analyze the use of NSAIDs after myocardial infarction.

“It is academically meaningful that the study presented new treatment strategies and evidence for a larger population group, beyond the existing studies centered only on Western population,” Choi said.