Nonsteroidal anti-inflammatory drugs (NSAID) are frequently used as over-the-counter and prescription medications.  Although prior studies have raised concern about the cardiovascular safety of these medications, detailed information on the risk of these medications in patients after myocardial infarction (MI) is lacking. In this study, retrospective Danish National Patient Registry data was evaluated for all patients >30 years old, admitted with first myocardial infarction (MI) between 2002-2011 and who survived to 30 days post-discharge.  All claimed medications were identified for anti-platelet agents and NSAIDS and evaluated as a time-varying covariate in the analysis to ensure outcomes were properly allocated when patients were or were not exposed. Importantly, the only over-the-counter NSAID available in Denmark is ibuprofen at low doses, thus reducing potential misclassification resulting from lack of data capture on over-the-counter use of NSAIDS. The primary study outcome was bleeding events with a secondary cardiovascular composite outcome of cardiovascular death, nonfatal recurrent MI, ischemic stroke, transient ischemic attach, or systemic arterial emboli.   In the final cohort of 61,971 patients, 34% had filled an NSAID prescription during the period of observation.  In multivariate adjusted models there was increased risk of bleeding with NSAIDS (HR 2.02, 95% CI 1.81-2.26) and increased risk of cardiovascular events (HR 1.40, 95% CI 1.30-1.49).  Notably this relationship was independent of anti-platelet treatment, NSAID type, or length of use.Conclusion:  Despite guideline recommendations to avoid NSAID use in patients with cardiovascular disease, about 1/3 of the cohort received an NSAID in this study.  NSAID use was associated with both increased risk of bleeding and cardiovascular events regardless of concomitant anti-thrombotic use.  Further education is necessary to reduce use of NSAIDs in this high-risk population.

Summarized by Lauren E. Thompson and Steven M. Bradley

• Schjerning Olsen AM, Gislason GH, McGettigan P, et al. Association of NSAID Use With Risk of Bleeding and Cardiovascular Events in Patients Receiving Antithrombotic Therapy After Myocardial Infarction. JAMA. 2015;313:805-814.