NSAIDs and Heart Failure: What’s the Connection?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are popular and highly effective pain relievers, but despite their widespread use, they do pose risks.

NSAIDs are known for multiple adverse effects, including gastrointestinal bleeding, cardiovascular side effects, and NSAID-induced nephrotoxicity (rapid deterioration of the kidneys). Most notably, these common pain relievers can raise your risk of heart failure, particularly if you have had a heart attack in the past.

This article will highlight the role of NSAIDs in heart failure and shed light on the specific NSAIDs that may put you at higher risk of a heart-related medical complication.

What Are NSAIDs?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications that are commonly used to reduce aches and pain and bring down a fever. These drugs, which are available over the counter and by prescription, work by reducing levels of the pro-inflammatory chemical prostaglandin.

NSAIDs are used to treat a wide range of conditions that cause inflammation, mild to moderate pain, and fever, including:

• Headaches and migraines (recurring headaches with moderate or severe pain)
• Colds and flu
• Sports injuries, such as sprains and strains
• Arthritis (swelling and pain in joints), rheumatoid arthritis (RA, an autoimmune disease affecting the joints), and other musculoskeletal disorders
• Menstrual cramps
• Postoperative pain

Anti-Inflammatory Drugs List

NSAIDs are one of the most versatile, inexpensive, and widely used drugs in the world. Some commonly used NSAIDs include:

• Bayer (aspirin)
• Motrin and Advil (ibuprofen)
• Aleve and Naprosyn (naproxen)
• Voltaren (diclofenac)
• Celebrex (celecoxib)
• Tivorbex (indomethacin)
• Mobic (meloxicam)
• Clinoril (sulindac)
• Feldene (piroxicam)

Some drug companies have even combined NSAIDs with other anti-inflammatory medications to treat pain associated with specific conditions. For example, the medication Excedrin combines acetaminophen, aspirin, and caffeine to treat migraine pain. 

How NSAIDs Work

Prostaglandins are hormone-like chemicals in the body that contribute to inflammation, pain, and fever by raising body temperature and dilating blood vessels. This causes redness and swelling in the place they are released.

Prostaglandins have a bad reputation because they make us feel lousy when we are sick. In truth, they are essential to our health as they protect the lining of the stomach and intestines from the damaging effects of acid, promote blood clotting by activating blood platelets, and make it possible for the kidneys to function optimally.  

When the body is in distress, it enters a pro-inflammatory state in its quest to fix the issue. This can cause us to experience pain and fever, prompting us to take NSAIDs.

NSAIDs work by blocking the enzyme cyclooxygenase (or COX), which is used by the body to make prostaglandins. The two types of COX enzymes are:

• COX-1 is present in most tissues all the time.
• COX-2 is mainly expressed in response to inflammation.

Both COX-1 and COX-2 produce prostaglandins that cause pain and inflammation, but COX-1 produces the group of prostaglandins that protect the lining of the stomach from acid and is an essential component of the blood-clotting process.

What Is the Link Between NSAIDs and Heart Failure?

If you have a history of cardiovascular disease or a weakened left side of your heart called left ventricular dysfunction, taking NSAIDs may worsen your heart failure.

This is because NSAIDs impair renal function (the working ability of your kidneys) by inhibiting the production of prostaglandin. As a result, water and sodium are retained and blood flow to the kidneys is reduced (marked by a lower glomerular filtration rate).

NSAIDs worsen kidney function, which throws off the homeostasis (balance) of the cardiovascular system. Retained fluid can overwhelm the weakened heart, a phenomenon called cardiac decompensation. Cardiac decompensation compromises the heart's ability to pump blood while also worsening kidney function due to poor blood flow.

Which NSAIDs Increase the Risk of Heart Failure?

Not all NSAIDs are problematic for the heart. For instance, aspirin is sometimes used as a blood thinner and may have a protective effect on the heart. The NSAIDs that pose the biggest risk include:

Ibuprofen: Research has found that ibuprofen, such as Advil and Motrin, can worsen existing high blood pressure (hypertension) or lead to the development of high blood pressure. These drugs also are linked to kidney damage (nephrotoxicity), worsening of heart failure, and even heart attack or stroke.

COX-2 inhibitors: When more COX-2 is blocked relative to COX-1, it can increase the risk of blood clots forming (thrombosis). This, in turn, raises the risk of adverse cardiovascular thrombotic events. Among the traditional NSAIDs, Voltaren (diclofenac), Celebrex (celecoxib), and Mobic (meloxicam) are relatively COX-2 selective.

Does Dose Matter?

The general rule of thumb is to use NSAIDs at the lowest effective dose for the shortest time possible should you need the medication. If you have heart failure, only use NSAIDs under the guidance of your healthcare provider.

What About OTC Ibuprofen?

Always discuss OTC ibuprofen use with your healthcare provider if you have diabetes, hypertension, or a history of heart failure. OTC ibuprofen, when used regularly, can cause or worsen heart failure although most people are usually fine using ibuprofen as needed for pain relief.

Should I Use NSAIDs If I Already Have Heart Disease?

Current guidelines for heart failure therapy recommend avoiding NSAIDs because they can cause sodium retention and vasoconstriction (narrowing of blood vessels). The drugs can also reduce the effectiveness and increase the toxicity of ACE inhibitors and diuretics.

Summary

By reducing the production of prostaglandins, NSAIDs help relieve the discomfort of fever and reduce the pain associated with inflammation. But if they are overused, they can cause or worsen heart failure, especially in those who are at high risk of cardiovascular disease, such as those with diabetes or hypertension, and people who have a prior history of heart failure. 

A Word From Verywell 

NSAIDs are one of the most used prescription and over-the-counter drugs in the world, but research shows that these drugs can elevate blood pressure, damage the lining of the stomach and kidneys, and worsen heart failure.

If you have high blood pressure, diabetes, or a weak heart, consult a healthcare professional before using this class of medication. For most people, short-term, occasional use is probably safe, but make sure to check your blood pressure regularly and try to get off them as soon as possible.