Why do doctors advise heart failure patients to just say no to NSAIDS?

I can hear you now:  NSAID?  Is that the new rapper who is dating the star of that new Netflix series?  ​No, NSAID is an acronym for the term non-steroidal anti-inflammatory drug.  Still not following me?
 
Well here is what the Cleveland clinic says about NSAIDS.  These drugs effectively reduce inflammation (swelling) and relieve pain.  Inflammation is the body's way of protecting itself after irritation or an injury. Signs of inflammation include redness, warmth, swelling, and pain.
 

Non-prescription NSAIDs include:

• Aspirin compounds (such as Anacin, Ascriptin, Bayer, Bufferin and Excedrin)
• Ibuprofen (such as Motrin and Advil)
• Naproxen sodium (such as Aleve)

For a number of years when I was growing up, I took Acetaminophen (also known as Tylenol) for my pain relief needs.  But in my thirties, I became the victim of wicked sinus headaches.  I decided to experiment with Motrin and Advil and found them to be much more effective for my sinus headaches and other aches and pains.
 
Imagine my frustration when I learned that as a heart failure patient, I needed to stay away from drugs in the NSAID category.  (Note:  you might recall that I am on a low dose aspirin, but that is under doctors’ order and is a low dose for the purpose of thinning blood and not treating pain).   I thought, well this is just great.  It had already become a metaphorical pain to live with heart failure.  But I figured my physical pain would be intensified if I could not take a drug that I had found to be effective.  If NSAIDs were not available to deal with pain, well what were my options?  And what was it about NSAIDs that caused them to be a risky drug for heart failure patients?

In a statement dated July 11, 2016, the American Heart Association cautioned that drugs used to treat a variety of conditions can cause or worsen heart failure.  The AHA encouraged patients to show each of their healthcare providers a complete list of medications, to include over the counter drugs and natural supplements.    This allows the providers to edit out drugs that could be harmful.  With respect to NSAIDs, the AHA statement said:

• In addition to prescription medications, over the counter drugs may also have unintended consequences for heart failure patients. For example, non-steroidal anti-inflammatory drugs (NSAIDs), including commonly used painkillers such as ibuprofen, can trigger or worsen heart failure by causing sodium and fluid retention and making diuretic medications less effective.

My first thought was here we go again!  Why does everything in my post-heart failure life seem to boil down to the curse of salt?  I recently had my DNA checked through Ancestry.com.  I do not recall that they discovered a genetic link to Lot’s wife, but it seems as though the curse of salt has plagued both of us!
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My  next thought was to look for other NSAID facts.  In addition to being a drug that is not recommended for heart patients, I found it interesting that the Cleveland Clinic also said that the use of NSAIDs should be avoided by patients who have Gastroesophageal Reflux Disease (also known as GERD).  I had GERD for a number of years before I retired (magically and thankfully my GERD disappeared within the first year of retirement).  I do not recall any doctor ever telling me that I should avoid NSAIDs because I had GERD.  My ignorance could have been due to the fact that the finding was made after I retired.  It also could have been due to the fact that prior to heart failure, I only saw a doctor for an annual physical, and we were not tracking my medications as closely as we do now.
 
Right now, the water retention aspect of heart failure is the one that can still cause me some challenges.  But is water retention the only heart issue that NSAIDs can aggravate?  According to the website Harvard Health, there are a number of issues that heart patients must keep in mind when looking to treat pain.  According to this website, NSAIDs pose a risk to the cardiovascular system for two main reasons. First, they change levels of substances in the blood that make clots more likely. A blood clot can block a narrowed artery in the heart, triggering a heart attack.

Second, and as already stated, NSAIDs change blood flow in the kidneys, causing the body to retain more salt and water.  In some patients, this can apparently cause blood pressure to rise, which also boosts the risk of a stroke. High blood pressure also makes people more prone to atrial fibrillation—a rapid, quivering motion of the heart's upper chambers. 

I do not have the high blood pressure issue, so hopefully that means I also do not have the atrial fibrillation risk.  But here are some other sobering findings about NSAIDs and atrial fibrillation. 

• A recent study found a higher risk of atrial fibrillation in people who had taken NSAIDs during the past 15 to 30 days compared with people who had never taken NSAIDs.

So I have concluded that the risks of NSAIDs to heart failure patients are very real.  So that leads back to the other question – what does a heart patient do for pain?  Well if you have had a heart attack or been diagnosed with a heart condition and you also have pain from an injury or a chronic condition like arthritis, here is a treatment approach recommended by the American Heart Association.  They recommend starting with a nondrug approach such as heating pads, ice, or physical therapy, if appropriate.

Even if these approaches don't eliminate your pain, they may let you take a lower dose of a painkiller.
Next, try aspirin or acetaminophen (Tylenol). I know, I previously said that Aspirin is an NSAID.  But apparently Aspirin is one NSAID that's actually good for the heart.  But on the down side, it can upset the stomach, lead to an ulcer, and cause bleeding in the digestive system.

Acetaminophen appears safe for both your heart and gut. "But according to the Harvard Health website, unlike NSAIDs, acetaminophen has no effect on inflammation, which is at the root of the arthritic conditions that plague many people.

​You should also be advised that there is another risk associated with acetaminophen.  High doses of acetaminophen can damage your liver.  So the advice I found on a number of websites is not to take more than 3,000 milligrams (mg) a day, keeping in mind that over-the-counter pills may contain 325, 500, or 650 mg of the drug. Additionally, a number of your cough and cold remedies combine various ingredients into one product.  So this means that acetaminophen can also be found in cough, cold, and flu products.  The advice is to check labels carefully, and also to use the lowest dose possible of any of these drugs for the shortest time possible.

Also on the list of over-the-counter drugs that heart failure patients need to exercise caution are antacids and decongestants. 

Okay, so I can hear you now saying: Geez Melanie!  How do you have the time, energy and brain power to keep up with all these diet, fluid and drug restrictions?  Well, you are right that keeping on top of all the heart failure restrictions is a freaking full time job.  Isn’t it a good thing that I am now retired and can fill my time with trolling the web for information on what might harm me and what will heal me?  I guess it is one of those examples of divine providence.  The damage caused by heart failure, and the ensuing treatment, has left me too tired and too unpredictable to pursue a full time job.  But my mind should never be left idle or bored, so isn’t it lucky that there are so many different things to learn about heart failure?

I guess in closing the best advice for the heart failure patient is to ask your cardiologist for a list of drugs that can worsen your heart failure. If it is necessary for you to take a drug that has a risk, make sure you and your doctor thoroughly discuss the risks versus the benefits and so that you and your doctor can make an informed decision.