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Ibuprofen May Up Heart Attack Risk

Ibuprofen, naproxen, and similar pain relievers raise a person's risk of heart attack, a new study suggests.

Ibuprofen and naproxen — traditional anti-inflammatory pain relievers — have been considered more heart friendly than the new Cox-2 type of pain drugs. Two of the Cox-2 drugs, Vioxx and Bextra, have been pulled from the market because they increase a person's risk of heart attack.

The new study, led by Julia Hippisley-Cox, MD, MRCP, of the University of Nottingham, England, did show that Vioxx increased the risk of heart attack by 32 percent. But it also linked ibuprofen — brand names include Advil and Motrin — to a 24 percent higher risk of heart attack compared with people who had not taken any anti-inflammatory in the last three years.

Diclofenac (brand names including Arthrotec, Cataflam, and Voltaren) increased heart attack risk by 55 percent. Naproxen (brand names include Aleve) was also linked to a higher heart attack risk, although the finding was not as strong.

In fact, a second study by Canadian arthritis specialist Marie Hudson, MD, MPH, found that among elderly patients who already had heart disease, Celebrex — a Cox-2 drug still on the market — was safer than Vioxx and possibly even traditional anti-inflammatory drugs.

Both studies appear in the June 11 issue of the British Medical Journal.

Read WebMD's "Special Report: Painkillers Under Fire."

Heart Attacks and Pain Pills

Hippisley-Cox and colleague Carol Coupland analyzed data collected from general practices across England, Wales, and Scotland. They analyzed data from 9,218 people with first-time heart attacks and compared them to 86,349 matched patients without heart attacks.

Those with heart attacks were much more likely to have used anti-inflammatory painkillers, also known as nonsteroidal anti-inflammatory drugs (NSAIDs).

"The list of traditional NSAIDs seems to be comparable to the Cox-2 drugs in increasing heart attack risk," says Hippisley-Cox, "but when you put that into perspective, the vast majority of people taking these drugs will not be harmed by them."

Older patients are at the highest risk of heart attack and thus more vulnerable to the increased heart risk from pain drugs. Hippisley-Cox calculates that Vioxx would cause one extra heart attack for every 700 patients aged 65 and older taking the drug. Ibuprofen would cause one extra heart attack for every 1,000 patients taking the drug.

Read Web MD's "10 Things You Should Know About Pain Relievers."

Pain vs. Side Effects

"Patients are taking painkillers because they are in pain," Hippisley-Cox says. "At the end of the day, we need to know the benefits and the risks. A young patient with arthritis has a low risk, so a 30 percent increase on that is quite small — whereas that person's dreadful pain is very likely to affect quality of life. So there is a trade-off of living without pain vs. the risk of side effects. The message to the consumer is not to panic and not to change treatment based on these study findings."

Interestingly, low-dose aspirin did not change a person's risk. Other studies have suggested that low-dose aspirin may offer some protection against the heart risks associated with pain drugs.

"The study suggests that the effects of NSAIDs are present whether or not patients are being prescribed aspirin," Hippisley-Cox says. "Aspirin does not cancel the risk out."

The British researcher is quick to note that her study does not prove anything. While it is a carefully done study, its findings are still preliminary. Only a well-designed clinical trial that randomly assigns patients to take one treatment compared to another can substantiate the findings.

Read Web MD's "Group Calls for Ibuprofen Warnings."

Celebrex a Better Choice?

In a smaller observational study, Hudson and colleagues looked at data on more than 2,200 patients aged 66 and over with congestive heart failure. All the patients needed a pain reliever.

"We know that in these patients, traditional NSAIDs and Cox-2 drugs are not generally indicated," Hudson tells WebMD. "But the fact is that some of these patients still need these drugs. For those who need them, we wanted to see if there are some that are better or worse than others."

The bottom line: Risk of death and recurrent heart failure appeared slightly lower in patients taking Celebrex.

"I am telling my patients who have heart failure and arthritis that the first-line treatment is still acetaminophen [Tylenol]," Hudson says. "But this does not always offer relief. So if I have to go on to [another] drug, I explain the increased risks. If I have to choose, I have been prescribing Celebrex."

The Hippisley-Cox and Hudson studies did not receive funding from drug companies. Neither of the researchers reports financial connections with the makers of any of the drugs under study.

Read Web MD's "Managing Your Risk Factors for Heart Disease."

By Daniel J. DeNoon, reviewed by Michael W. Smith, MD

SOURCES: Hippisley-Cox, J. British Medical Journal, June 11, 2005; vol 330: pp 1366-1372. Hudson, M. British Medical Journal,June 11, 2005; vol 330: pp 1370-1375. Julia Hippisley-Cox, MD, MRCP, MRCGP, DRCOG, professor of clinical epidemiology and clinical practice, University of Nottingham, England. Marie Hudson, MD, MPH, rheumatologist and postdoctoral student, McGill University.