March 21, 2018

expert reaction to NSAIDs and atrial fibrillation

A nationwide population-based cohort study examines the association between nonsteroidal anti-inflammatory drugs and atrial fibrillation.

Dr Amitava Banerjee, Senior Clinical Lecturer in Clinical Data Science and Honorary Consultant Cardiologist at UCL, said:

“Previous studies have highlighted that nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with increased risk of atrial fibrillation (AF), the world’s commonest heart rhythm disorder, which in turn increases the risk of ischaemic stroke. In fact, in 2014, Liu and colleagues published a meta-analysis of existing studies, showing a 53% increased risk of AF with NSAIDs (https://www.ncbi.nlm.nih.gov/pubmed/25260945).

“This new study is of a moderate quality, in that it is a case-control design and other higher quality studies from other countries have already found similar results. Therefore, in terms of level of evidence, it is the most open to bias and confounding, compared with cohorts and trial designs. Its novelty is that the study population was based in Taiwan. The majority of AF epidemiologic research has been done in predominantly Caucasian populations, and therefore findings do need to be replicated in other ethnic groups.

“When prescribing NSAIDs, the risk of cardiovascular disease must be taken into consideration and the growing literature about the risk of AF adds to this evidence. Particularly in individuals with pre-existing cardiac disease (e.g. heart attacks), the risk of AF is likely to be higher with NSAIDs.”

Prof Tim Chico, Professor of Cardiovascular Medicine and Honorary Consultant Cardiologist at the University of Sheffield, said:

“This is a well-conducted review of three databases in Taiwan, which compared middle aged patients (older than 45) with an abnormal heart rhythm called atrial fibrillation to those without. The researchers found that the patients with AF were a little more likely to be taking NSAIDs (about 1.18 times the rate of people without AF). These results fit with other studies that shows that NSAIDs are associated with a slight increase in heart problems including heart attack or a reduced efficiency of the heart.

“This and other studies do show that people taking NSAIDs are more likely to have AF, although the increased risk for this is relatively small compared with things like obesity and high blood pressure. For example, a 6 foot man who weighs 80kg is of a normal body mass index, but if they weigh 110kg their risk of AF would increase by 1.5 times, while having high blood pressure may increase risk of AF by up to 2 times (i.e. double).

“The fact that people who take NSAIDs are more likely to have AF does not mean that the drug itself causes the AF; this may be due to other factors such as their weight (which wasn’t measured in this study) or level of physical activity. However, the evidence is now fairly clear that NSAIDs almost certainly do directly increase the risk of certain types of heart disease, and it would not be surprising if they increase the risk of AF.

“The implications of this research are that NSAIDs, even though they are available over the counter are not without risks. All medications and drugs have side effects, and NSAIDs have a range of possible side effects, many of which are serious although these tend to be rare. For these reasons it is sensible to only take them when needed, and for only as long as needed. I do have patients who suffer pain that NSAIDs control effectively, and I would advise anyone to discuss the risks and benefits of their medications with their GP.”

Dr Charles Pearman, Clinical lecturer in Cardiovascular Science at the University of Manchester, said:

“Like all medicines, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen and diclofenac can have side effects. These drugs are already known to increase the risk of stomach ulcers and kidney problems, and some NSAIDs may increase the risk of heart attacks.  This study adds to others suggesting that, in addition to the other well-known side effects, taking NSAIDs may be linked to a slightly higher risk of heart rhythm problems.

“Comparing more than 28,000 Taiwanese patients with an irregular heart rhythm called atrial fibrillation (AF) to a similar number without the condition, an extra one in twenty patients with AF had been prescribed NSAIDs within the last year.  To put this into context: 31 out of every 100 patients with atrial fibrillation had been prescribed an NSAID compared to 26 out of every 100 patients without AF, an increase of 5 patients per 100.  This study by itself does not prove that NSAIDs cause heart rhythm problems, as something that the investigators didn’t measure could link the two – for example patients who are obese may be more likely to develop AF and at the same time be more likely to take NSAIDs.  It also did not take into account patients who bought NSAIDs over the counter.

“However, despite the known side effects and the possibility of an increased risk of abnormal heart rhythms, anti-inflammatories can be a very useful treatment.  Patients should consult their doctor before making any changes to their medication.”

Prof Roger Knaggs, Associate Professor in Clinical Pharmacy Practice at the University of Nottingham, said:

“Nonsteroidal anti-inflammatory drugs (NSAIDs) are used commonly by many people to manage a wide range of painful conditions. This large observational study found that people in Taiwan taking NSAIDs had a slightly increased risk of developing atrial fibrillation, a type of irregular heartbeat, compared with people who were not taking them. However, it does not mean that taking NSAIDs was the cause and this replicates the findings of similar studies in different countries.

“The study controlled for many potential confounders, such as other conditions, that may predispose the development of atrial fibrillation. People who developed atrial fibrillation most commonly did so soon after starting to take NSAIDs.

“Other effects of NSAIDs on the heart, including heart attack, stroke, and heart failure, have become apparent over recent years.

“The results emphasise the need for NSAIDs to be used at the lowest dose for the shortest period, and that the importance of regular review of both effectiveness and side effects.”

* ‘ Association between Nonsteroidal Anti-inflammatory Drugs and Atrial Fibrillation among a Middle-aged Population: A Nationwide Population-based Cohort’ by Shao-Yuan Chuang et al. published in the British Journal of Clinical Pharmacology at 4.01am UK time on Wednesday 21st March 2018. 

Declared interests

Dr Amitava Banerjee: I have no competing interests.

No others received.