There has been yet more suggestion that even commonly used nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Nurofen) and diclofenac (Difene) are dangerous for heart failure patients.

A new study published in January 2009 linked re-admittance to hospital and an increase in risk of death with COX-2 inhibitors and other NSAIDs. This was particularly apparent for sufferers of heart failure or myocardial infarction (MI). The research used records of hospitalization and pharmacy drug dispensing in Denmark. Details of 107,092 patients who survived their first heart failure related hospitalization between 1995 and 2004 were studied, alongside their use of NSAIDs.

33.9% of these patients received at least one NSAID prescription after their discharge from the hospital, 56.9% of them died during the follow up period, and 8.4% and 37.5% were re-admitted to the hospital with MI or heart failure. The analysis of the collected data showed a clear dose related increase in risk with NSAID use for these patients.

Dr Gunnar Gislason, from Gentofte University Hospital in Denmark, who was the leading author said: "Although our study is observational, and you can never exclude all confounding factors, we have very consistent results estimated using two different statistical methods. And these results are similar to many other previous studies. In addition, we see a strong dose-related response. I think the data are very convincing."

COX-2 inhibitors are not the only offenders in heightening risks. Diclofenac (Difene, Diclac, Voltarol, Cataflam) also showed comparable results in the tests. Dr Gislason described this statistic as "very disturbing" because of the drug’s wide use and availability in many countries.

He went on to say that the effects are "quite considerable". Rofecoxib showed one death in nine patients treated for a year, while celecoxib showed a one in 14 rate, closely followed by diclofenac at one in only 11. Gislason described these numbers as "very low", considering that with antihypertensive drugs you need to treat 50 to 100 patients for a year to save just one patient.

"Everyone agrees that it is worth treating hypertension. So the harmful effect of some NSAIDs is much greater than the beneficial effect of antihypertensive treatment... Our results suggest that all NSAIDs have harmful effects in heart-failure patients, even naproxen at high doses. Naproxen [Naprosyn] is probably the best of the bunch, but it still increases fluid retention, which is bad news for heart-failure patients," said Gislason.

He does not believe that doctors are aware of the problems related to these drugs, as they are still being widely prescribed: "We need to raise awareness. I think the main culprits are primary-care doctors, as these drugs are so widely prescribed in general practice... The fact that some of these drugs are available over the counter makes the situation much worse, as anyone can buy them without advice from a doctor."

Gislason goes on to say that NSAIDs should only be available with a prescription and not readily over the counter. Such easy availability suggests little to no risk involved with taking them. There is also the risk that those who suffer from heart disease will not be aware that they shouldn’t be taking them.

It is advised that all heart failure patients avoid NSAIDs if at all possible, but if not, then ensure to take a more COX-1 selective NSAID, with a low dose and for only a short period of time. Gislason concluded: "I know NSAIDs are useful drugs, and they will always be used to some extent, but we need to be careful about which drug is selected and which dosage used. More thought should go into trying to combine them with other agents so that a lower dose could be used."

L.W.