If you’re experiencing chronic pain, you may not realize that regularly popping an over-the-counter (OTC) pain reliever can have consequences, especially if you’re at high risk of cardiovascular problems like heart attack or stroke. Cardiologist Helga Van Herle, MD, MS, explains what she tells her patients about relieving pain in heart-healthy ways. 1. Q: First of all, who is at a high risk for cardiovascular events? A: Patients that are high risk are those who have a strong family history of early heart disease, and/or a history of diabetes, high cholesterol, high blood pressure, or smoking. And, of course, you’re at high risk if you’ve already had either a heart attack or stroke, or the equivalent of a heart attack or stroke, like if you’ve had a bypass surgery or a stent placed in your coronary artery. 2. Q: Why do patients at risk of heart problems need to be concerned about taking pain relievers? A: The most common over-the-counter pain relievers are nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol). NSAIDs like ibuprofen (Advil) and naproxen (Aleve) have been shown to affect cardiovascular health in a few ways. Many people with heart disease risk take a low dose of aspirin daily, because aspirin can prevent blood clots, which are a cause of heart attacks and strokes. However, we’ve seen in studies that if you take an aspirin within eight hours of taking an NSAID like ibuprofen, this inhibits the ability of aspirin to prevent clots, so you’re not getting what you need from the aspirin. Additionally, NSAIDs can worsen blood pressure control and even raise blood pressure if taken chronically, so for people at high risk of heart problems, they should be avoided. Studies have shown that, especially in patients who have had a previous heart attack or other form of coronary artery disease, chronic NSAID use is associated with an increased risk of death, nonfatal heart attack, and nonfatal stroke. We believe this is because NSAIDs may inhibit a substance called prostacyclin, which helps dilate arteries in the blood. When prostacyclin is blocked by NSAIDs, this causes the arteries to constrict, or tighten, which can lead to heart attack or stroke. NSAIDs also inhibit an enzyme that helps to form nitric oxide, which is a beneficial substance made by the lining of the heart vessels that helps prevent arteries from constricting. Because of these issues, we’re concerned about people taking NSAIDs chronically, especially heart patients and patients at high risk for heart disease. 3. Q: So if NSAIDs should be avoided, is acetaminophen a good replacement? A: I see a lot of older patients with heart problems and chronic pain, and treating them can be tricky. NSAIDs reduce inflammation, which reduces pain, so for patients with inflammatory conditions like osteoarthritis, NSAIDs seem to be ideal. However, because of the heart risk, I’d prefer that they take acetaminophen or try another option. Acetaminophen doesn’t reduce inflammation, so it’s not as effective as NSAIDs in controlling inflammatory pain. We don’t know exactly how acetaminophen works, but it’s thought to inhibit an enzyme in the brain that receives pain signals. If acetaminophen isn’t doing the trick, I always recommend non-pharmacological pain relief options, like physical therapy, massage, relaxation techniques, acupuncture, hot and cold therapy, stretching, and exercising. On occasion, it’s okay if heart patients consider NSAIDs, when acetaminophen is not going to effectively treat their pain; for example, pain from a muscle sprain would benefit more from the anti-inflammatory effects of NSAIDs. In those cases, I’ll talk about the risks of NSAIDs with my patients, and encourage them to take as low a dose as possible. It’s also important to take NSAIDs for only a short period of time. However, if someone has had a recent heart attack, I don’t want them to be on an NSAID at all, so we’ll talk about other options to manage pain. Essentially, every patient's case is unique. Patients and their doctors should discuss together the risks and benefits of pain relievers for their specific situation. In general, for all patients, regardless of heart disease risk, all pain relievers should be taken with caution. NSAIDs come with side effects that can be severe, like stomach bleeding. And acetaminophen, which is different from NSAIDs, can be toxic to the liver if you take more than the appropriate dose. 4. Q: What’s the bottom line about pain relief and heart disease? A: For all patients, it’s important that you tell your doctor if you’re taking NSAIDs or any other over-the-counter drug, including herbal supplements. In my clinical practice, I often note that patients only list or mention the prescription medications that they are taking and do not include OTC medications they take on a regular basis, like ibuprofen or naproxen. It is especially important information for physicians to have, particularly for treating patients with heart disease or a high risk of heart disease. I think all patients need to realize that these pain relievers are not benign, harmless medications. And it’s really important, if patients have chronic pain issues, that they’re in touch with somebody from the medical profession who can help guide them through treatment options and therapies. There are a lot of risks with self-medicating for pain, especially for patients with multiple medical issues.