NSAIDS : Cardiovascular Risks

Recommendations: 

• In those patients in whom an NSAID is necessary, we recommend short-term use of naproxen 
• If naproxen or another NSAID is required, it should be used at the lowest effective dose and for the shortest duration necessar
• Do not use NSAIDs in patients with recent acute myocardial infarction (MI), unstable angina, or poorly compensated heart failure (HF), nor during the perioperative period in patients undergoing coronary artery bypass surgery
• Coxibs, diclofenac, and ibuprofen increased the absolute annual excess risk of a major vascular event to a similar degree in these patients; naproxen did not increase such risk.

Heart failure 

• The use of nonselective NSAIDs increases the risk of HF, including the exacerbation of preexisting HF.
• There was a dose-dependent increase in risk of death, which was highest with diclofenac. Higher doses of ibuprofen (>1200 mg/day) and naproxen (>500 mg/day), but not lower doses, were also associated with an increased risk of death

Hypertension 

•  NSAIDs can raise the blood pressure and worsen control of hypertension in patients already being treated.
• if blood pressure becomes elevated while using NSAIDs, discontinuing or reducing the dose of the NSAID is generally preferred over adding antihypertensives, when possible.

Systemic Inflammatory Disease

• The effect of nonselective nonsteroidal antiinflammatory drugs (NSAIDs) on cardiovascular risk is less clear in patients with systemic inflammatory disorders such as rheumatoid arthritis (RA). Cardiovascular risk is increased in patients with RA.
• Some disease-modifying antirheumatic drugs (DMARDs) have a protective effect.

Aspirin

• For patients taking aspirin, we believe the use of NSAIDs is reasonable in patients for whom they are clearly indicated, despite a concern regarding a potential negative interaction. In these patients, we prefer naproxen to other agents.
• advise the patient that aspirin be taken at least two hours before taking a nonselective NSAID or that an alternative agent that does not interfere with the effects of aspirin on platelets (eg, acetaminophen) be used instead, although the data are limited

References:

1. www.uptodate.com
2. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): The Risks and Benefits, November 2015.