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Your Weekly Checkup: New Dangers Found in a Common Pain Reliever

“Your Weekly Checkup” is our online column by Dr. Douglas Zipes, an internationally acclaimed cardiologist, professor, author, inventor, and authority on pacing and electrophysiology. Dr. Zipes is also a contributor to The Saturday Evening Post print magazine. Subscribe to receive thoughtful articles, new fiction, health and wellness advice, and gems from our archive.

Order Dr. Zipes’ new book, Damn the Naysayers: A Doctor’s Memoir.

I have previously called attention to the cardiovascular risks of taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen, celecoxib , acetaminophen, and diclofenac. Available in prescription strength and (for some medications) over-the-counter, NSAIDs interfere with the production of chemicals in the body called prostaglandins that reduce inflammation and pain and can increase the risks for developing heart attacks and strokes.

In a recent study that was the largest analysis ever conducted of cardiovascular risk associated with NSAIDs, diclofenac surfaced as the NSAID with the highest risk for causing adverse cardiovascular outcomes. Because diclofenac is a very popular and frequently used NSAID, its negative impact on cardiovascular outcomes becomes even more important.

For this study, the authors used the Danish health registry to analyze 1,370,832 people who started using diclofenac, 3,878,454 who started using ibuprofen, 291,490 who started using naproxen, 764,781 who started using acetaminophen and 1,303,209 who took no NSAIDs. The results for diclofenac were pretty damning.

They found that the 30-day adverse event rate for major cardiovascular events among people who started taking diclofenac increased by 50% compared with those who didn’t take the drug, by 20% compared with acetaminophen or ibuprofen users, and by 30% compared with naproxen users. The relative risk of major adverse cardiovascular events was highest in people with low or moderate baseline risk (that is, diabetes mellitus), while the absolute risk was highest in people with high baseline risk (that is, previous heart attack or heart failure). Diclofenac users in the highest risk group had up to 40 excess cardiovascular events per year per 1,000 people – about half of them fatal – that were attributable to starting the medication.

The increased risk was observed for those with heart rhythm problems of atrial fibrillation or flutter, stroke, heart failure, heart attacks, and cardiac death; both sexes of all ages; and even at low doses of diclofenac.

Diclofenac also increased the risk of upper gastrointestinal bleeding at 30 days, by approximately 4.5-fold compared with no use of any NSAIDS, 2.5-fold compared with use of ibuprofen or acetaminophen, and to a similar extent as naproxen.

The authors concluded that the treatment of pain and inflammation with NSAIDs may be worthwhile for some patients to improve quality of life despite potential side effects. However, considering the cardiovascular and gastrointestinal risks associated with diclofenac use, there was little justification to initiate diclofenac treatment before trying other traditional NSAIDs that had lower cardiovascular risk. When diclofenac was used, it should be accompanied by appropriate warnings of its potential cardiovascular risks.

Try to avoid NSAIDs if you can. Consider acupuncture, meditation, stretching, or other methods to relieve common aches and pains. If you need to take NSAIDs, try to keep the dose as low as possible, and take the NSAID as infrequently as possible.

Your Weekly Checkup: Psychological Distress Can Have Physical Consequences

Order Dr. Zipes’ new book, Damn the Naysayers: A Doctor’s Memoir.

Many people are distressed — maybe at work performing a job they don’t like or working for a boss who doesn’t like them. Or maybe they are stuck in a marriage that is on the rocks or struggling with misbehaving or uncontrollable children.

All of us, at one time or another, deal with stress in our lives. For most, the stress is transient and ultimately resolvable. But for some, the stress is longer lasting, even constant, severe, and insoluble.

These are the people I worry about because they are at increased risk for heart attacks and strokes. A recent study analyzed information from almost a quarter of a million participants with no history of heart attack or stroke. The investigators calculated and ranked psychological distress, such as fatigue, anxiety, depression, and hopelessness experienced by each participant within the previous four weeks.

When the study started, 16.2% of participants had moderate psychological distress while 7.3% had high or very high psychological distress, greater in women than men. Over the next 4.7 years, 4,573 heart attacks and 2,421 strokes occurred. The higher the degree of psychological distress, the higher the absolute heart attack and stroke risk among the participants. In men aged 45 to 79 years, those with high or very high psychological distress had a 30 percent greater risk for heart attack compared with those with lower psychological distress. The risk was less among men 80 and older. However, male sex added to the effects of the psychological stress. Among women, those with high or very high psychological distress had an 18% greater risk for heart attack compared with those with lower psychological distress and did not change with age.

The stroke risk also increased. Among those aged 45 to 79 years, high or very high psychological distress was associated with a 24% increased risk for stroke in men and 44% increased risk in women. Therefore, in woman, the magnitude of the effect of psychological distress appeared greater for stroke than for heart attacks. The reason for this is not known.

The results from this study — one of the largest of its kind — make it very clear that psychological stress has a strong, dose-dependent association with heart attacks and strokes in men and women, despite adjustment for a wide range of confounders.

How might the head impact the heart or brain to cause a heart attack or stroke? A recent study showed that patients who had post-traumatic stress disorder (PTSD) after a heart attack exhibited enhanced inflammatory responses to psychological stress. This observation provides a potential link — inflammation — between PTSD and adverse cardiovascular outcomes as well as other diseases associated with inflammation.

What can distressed people do? In some instances, antidepressant drugs can reduce the risk for cardiac events. In 300 patients with depression following an acute coronary syndrome, a 24-week treatment with an anti-depressant, escitalopram, compared with placebo resulted in a lower risk of major adverse cardiac events after a median of 8.1 years.

If you are distressed or depressed, seek professional help. Much can be done to relieve the stress to make you feel better and reduce the risk for a heart attack or stroke.