Selective versus non-selective NSAID and blood pressure impact
A reduction as small as 2 mm Hg can lower cardiovascular risks among patients with cardiovascular disease (CVD), says an expert.
According to Dr Jeffrey Borer, a 2 mm Hg difference in mean systolic blood pressure (SBP) can result in a 7 percent reduction in the risk of ischaemic heart disease and a 10 percent reduction in the risk of stroke mortality. Borer is Professor of Medicine, Cell Biology, Radiology and Surgery at the State University of New York Downstate Medical Center, US. [Lancet 2002;360(9349):1903–1913]
Borer was speaking about blood pressure (BP) in relation to the results of the PRECISION-ABPM* study, which is a substudy of PRECISION**. PRECISION looked at the safety of celecoxib against ibuprofen and naproxen and arrived at the conclusion that, in moderate doses, celecoxib was noninferior to ibuprofen or naproxen in terms of CV safety.
[Noninferiority (NI) trials test whether a new experimental treatment is not inferior to the standard by too large an amount.]
However, nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) and selective inhibitors of COX-2 can increase BP or interfere with BP control. As alluded earlier, even small differences in blood pressure may affect CV morbidity and mortality in a population. The PRECISION-ABPM study was conceived as a priori sub study to “delineate differential BP effects and the relationship between changes in ambulatory blood pressure and subsequent cardiovascular events of celecoxib versus ibuprofen and naproxen.”
What PRECISION-ABPM arrived at was that participants in the non-selective NSAID ibuprofen experienced a significant increase of SBP, and a higher incidence of new-onset hypertension compared with those in the COX-2 selective inhibitor celecoxib arm. [European Heart Journal doi: 10.1093/eurheartj/ehx508] Borer said: “These results support and extend the findings of PRECISION trial demonstrating noninferiority for the primary cardiovascular outcomes for moderate doses of celecoxib compared with naproxen or ibuprofen.”
Additionally, since PRECISION-ABPM demonstrates differential effects of NSAIDS on BP, Borer called on clinicians to “weigh the potential hazards of worsening BP control and its clinical sequelae as well as the risks to GI safety when considering the use of these agents, in particular ibuprofen.” This applies mostly to the elderly who are more likely to have high BP and arthritis.
ABPM helps in diagnosis and management of high BP
At the same session, Borer also brought up the use of 24-hour ambulatory blood pressure measurement (ABPM) in his practice. Borer said: “BP changes from minute to minute, hour to hour, and day to day. By sampling more frequently, then you’re more likely to arrive at a number that’s more meaningful to a patient than if you take one BP reading.”
Sometimes, a person can be deemed to have high BP due to the white coat effect. Borer said some patients who are deemed to have high BP from office visits often don’t exhibit high BP in 24-hour ambulatory readings.
“I regularly test my patients’ 24-hour ambulatory blood pressure before starting treatment. The second time I’ll use the [24-hour ABPM] reading when I’ve started treatment—to see if the treatment is working.”
*PRECISION-ABPM: Prospective Randomized Evaluation of Celecoxib Integrated Safety Vs Ibuprofen Or Naproxen-Ambulatory Blood Pressure Measurement
**PRECISION: Prospective Randomized Evaluation of Celecoxib Integrated Safety Vs Ibuprofen Or Naproxen