Often, I think people don’t realize that their over-the-counter (OTC) medications are not benign, harmless things. Medications like allergy pills, cold medicines, and pain relievers can have significant side effects that impact the body in different ways. The problem is, since these products are OTC, patients aren’t getting any guidance about how to take them safely. As a cardiologist, one of my major concerns is when patients take nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen (Advil) and naproxen (Aleve) for pain relief. For all patients, NSAIDs come with the potential for side effects like stomach bleeding. But for my patients who are at a higher risk of heart problems, NSAIDs pose a more serious threat. We consider you to have a high risk of adverse cardiovascular events if you have a strong family history of early heart disease, diabetes, high cholesterol, hypertension, or smoking. You’re also a high-risk patient if you’ve already had a heart attack, stroke, or other heart-related problem. Here’s a frustrating situation that I come across often: my patients are at high risk of heart problems, so I’d prefer they avoid NSAIDs, but they also are suffering from pain related to inflammatory conditions, which are best treated with NSAIDs. Because of this catch-22, it’s important that I discuss with each patient the best pain relief technique for his or her individual situation. If a patient has made healthy lifestyle changes to improve heart health, and has never had a heart attack or stroke, then I might approve short-term NSAID use for temporary pain. But if a patient has recently had a heart attack, I don’t want him to be on an NSAID at all. I’ll suggest acetaminophen (Tylenol), as well as non-pharmaceutical methods of pain relief, like physical therapy, massage, relaxation techniques, acupuncture, hot/cold therapy, stretching, and exercising. NSAIDs work by inhibiting your body’s inflammatory response—this response can cause pain, so blocking it reduces your pain. To do this, NSAIDs block enzymes in the body called cyclooxygenases (COX). These enzymes produce substances called prostaglandins, which create inflammation and can cause pain in high levels. So by inhibiting these enzymes, NSAIDs can help prevent and reduce pain and inflammation. However, when these enzymes are blocked, this leads to side effects; for example, prostaglandin coats the lining of your stomach, which prevents gastrointestinal bleeding. When NSAIDs block prostaglandin, they remove this protective lining and increase your bleeding risk. NSAIDs also may inhibit a substance called prostacyclin, which helps keep your arteries clear and prevents clots. They also block one of the enzymes that helps to form nitric oxide, which is a beneficial substance made by the lining of the heart vessels that prevents artery obstruction. And NSAIDs have been shown to increase blood pressure over time in patients who take them frequently and consistently. These side effects are thought to be the reason that one major study, called the INVEST trial, found that chronic NSAID use is associated with an increased risk of death, nonfatal heart attack, and nonfatal stroke in patients with heart disease. If you’re at high risk of heart problems, you might be taking a low dose of aspirin daily to reduce your risk of heart attack or stroke. Aspirin prevents blood clots from forming in your arteries, which can cause heart attack or stroke. However, studies have found that if you take an aspirin within eight hours of taking ibuprofen, aspirin isn’t as effective in preventing blood clots. For these reasons, I’m always concerned when heart patients tell me that they take NSAIDs often for aches and pains. I encourage patients to try other pain relief options, like acetaminophen, which works differently from NSAIDs. We’re not exactly clear on how acetaminophen works, but we believe it interferes with the brain’s pain response. Acetaminophen has virtually no side effects if taken at the recommended doses. If you exceed the daily dose, however, there’s a risk of severe liver problems. But, in general, acetaminophen is a better option for heart patients. The problem is, acetaminophen is not an anti-inflammatory. Often, my patients experience pain from inflammatory conditions, like osteoarthritis. In these cases, acetaminophen is not as effective as NSAIDs at reducing pain and inflammation. Determining the best way to get pain relief really depends on the patient—how high his or her heart disease risk is, whether or not he or she has already experienced a heart attack or stroke, whether or not he or she is taking aspirin, and how much the pain is impacting his or her life. Because this decision is so important and so complex, it’s imperative that anyone with chronic pain develops a relationship with a medical professional. Especially if you are at high risk of heart problems, the over-the-counter medications you’re taking can have real consequences on your health. Next time you’re at your doctor’s office, make sure to write down your OTC medications, as well as your prescribed ones, so your physician has a full idea of how to guide you in the right direction.