"Based on this, we have to assume that if you've ever had a heart attack, you should use NSAIDs with caution, and only in consultation with your doctor," said Dr. Gordon Tomaselli, chief of cardiology at Johns Hopkins University in Baltimore.

NSAID stands for non-steroidal anti-inflammatory drugs. In a study of almost 100,000 first-time heart attack sufferers, researchers found that those who used the medications afterward were more likely to have a repeat heart attack or die over the next five years.

In the first year after the heart attack, 20 percent of NSAID users died, versus about 12 percent of non-users.

Death rates in both groups then declined over the next four years. But NSAID users' rate remained about double that of non-users.

The findings suggest that painkiller use "should be on the list of things you talk about with your doctor" soon after a heart attack, said Tomaselli, who was not involved in the study and is immediate past president of the American Heart Association (AHA).

NSAIDs include over-the-counter painkillers like aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve), as well as prescription arthritis drugs known as COX-2 inhibitors.

OVER-THE-COUNTER CONCERNS

With the exception of aspirin, which is known to cut the risk of heart attack, the safety of NSAIDs for people with heart disease has long been in doubt.

It started with COX-2 inhibitors, which were linked to increased risks of heart attack and other cardiovascular problems. Two of the drugs - rofecoxib (Vioxx) and valdecoxib (Bextra) - were pulled from the market in 2004 and 2005; a third, celecoxib (Celebrex), is still prescribed.

Studies since then have also raised questions about over-the-counter NSAIDs.

Since 2007, the AHA has advised that people with heart disease first try acetaminophen (marketed as Tylenol) or aspirin when they need pain relief.

If that's not enough, an NSAID, at a low dose and for a short time, may be needed. Some studies have suggested that of the NSAIDs, naproxen is safest for the heart - but that's still being studied.

What hasn't been clear is whether the risks connected to NSAIDs change over time.

The new findings suggest the drugs "have no apparent safe treatment window among patients with (heart attack)," lead researcher Dr. Anne-Marie Schjerning Olsen, of Copenhagen University Hospital Gentofte, told Reuters Health by email.

NEARLY 100,000 STUDIED

The study, reported in the journal Circulation, is based on records from 99,187 Danish adults who suffered a first-time heart attack between 1997 and 2009.

Based on pharmacy records, 44 percent were prescribed an NSAID at some point after the heart attack. (During the study period, ibuprofen was the only NSAID available over the counter in Denmark, according to the researchers.)

Over the follow-up, nearly 29,000 people had a repeat heart attack or died of cardiovascular problems. The risk was higher among NSAID users, even when Olsen's team accounted for patients' age, other medical conditions and certain other factors.

Both Olsen and Tomaselli said this type of study can only point to a link between NSAIDs and heart risks, and cannot on its own prove cause and effect.

But, Tomaselli said, a number of studies have now consistently uncovered the same pattern. And there are biological reasons to believe non-aspirin NSAIDs could be risky to people with heart disease, he added.

There's evidence, for instance, that the drugs may affect blood clotting, blood vessel function and blood pressure.

A limit of the current study is that the researchers do not know why people were using NSAIDs, or exactly what dose they were on.

"We don't know if taking them once in a while, for your sore muscles, would have the same risks" as more chronic NSAID use, Tomaselli said.

But it's best to be cautious, he said, and talk with your doctor about all pain reliever use.

Olsen noted that in Denmark, NSAID use among heart patients "has not declined at all" since the potential hazards have emerged.

"I therefore think we need better education, particularly of general practitioners, who tend to prescribe these drugs to many patients," she said.

The fact that some NSAIDs are available over the counter may also lead consumers to believe they are completely safe, Olsen noted.

"People need to know that NSAIDs are still dangerous to patients with a history of (heart attack)," she said, "even five years after their event."

SOURCE: bit.ly/U76FTp Circulation, online September 10, 2012.

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