Atrial fibrillation General Medicine

Atrial Fibrillation and NSAIDs

Sunday nights in Autumn means one thing for this doctor-cyclocross racer: aches and pains.  Tonight, just as the thought popped into my head: “a few Alleve(s) probably wouldn’t fire up that reflux very much,”  I hear from the computer room…

“Hey John, how much alleve were you taking when you had your AF,” asked my wife, doctor, and our family’s internet researcher of all things healthy.

Gosh, it seems everything can cause AF: beer, wine, chocolate, obesity, high blood pressure, sleep apnea, stress, and of course, the worst one of all, birthdays.

Now there may be yet another culprit to add to that list. As reported by, an Italian group of researchers published a retrospective population study (in the Archives of Internal Medicine) suggesting that the continued use of non-steroidal anti-inflammatory drugs (NSAIDs)–common OTC brands are Ibuprofen, Naprosyn, Motrin, Alleve–may increase the risk of having permanent AF.

Oh no. Everyone takes these medicines at one time or another, especially bike racers.

Wait a second though; before getting too bent out of shape over this new finding it bears strong mention that this study is far from conclusive. It was neither randomized, prospective, controlled or blinded. The study was simply a look back at patients’ diagnosis and their medicines. Such retrospective population studies are merely hypothesis-generating, not conclusive.

That said, the potential relationship between AF and arthritis medicine is believable, as arthritis and AF live in the same neighborhood.  The authors mention the possibility that patients who require anti-inflammatory measures have an excess of inflammation, and inflammation is implicated strongly in AF. That one makes some sense.

There are other likely causes for such an association as well.

  • NSAIDs are strongly associated with (and likely directly causative of) high blood pressure. It consistently amazes me, in this age of information, how under-appreciated this fact is.  And high blood pressure is the disease most often associated with AF. 
  • Arthritis patients hurt. Thus they probably exercise less, and as such are at risk for obesity. Obesity causes AF.
  • Arthritis patients hurt at night. Thus they probably sleep less well.  Sleep disorders cause AF.

There are oodles of reasons not to take NSAIDs on a regular basis.  Despite their ubiquity they are surprisingly dangerous.  NSAIDs have numerous adverse effects: gastrointestinal disturbances like reflux, ulcers and serious bleeding (the transfusion kind), kidney failure, high blood pressure, and those terrible, those horrible, those unsightly puffy ankles.

Perhaps now doctors can use this study–in a stretch the truth, the ends justify the means sort of way–to say that NSAIDs may cause the heart to hiccup. Maybe then the patient will say something along these lines, “Heart problems?…That’s it…I surely will stop that medicne…I never knew it could cause heart problems.”  (Well, we probably shouldn’t get our hopes up too much, as cigarettes, hot dogs and donuts cause heart disease and these toxins have proven hard habits to break.)

Ironically, one needs a prescription for an innocuous beta-blocker for palpitations, an albuterol inhaler for wheezing or a steroid cream for poison ivy, but one can have their wellness threatened by an OTC remedy for life’s aches and pains.

Lest you think me insensitive about orthopedic pain, I can provide many references in the cycling community who can vouch for my first-hand knowledge of such discomfort.


4 replies on “Atrial Fibrillation and NSAIDs”

I have rheumatoid arthritis. While my pain isn't severe right now, I always have some pain, somewhere, and inflammation is always there. I don't take any NSAIDs at the moment, but have taken them frequently and at length in the past. For many people with RA they're helpful in battling the pain that comes with the inflammation.

Given this new reason to be concerned about taking NSAIDs, have you any suggestions for alternative therapies? Many of us take these meds knowing the possibility for dangerous, even life-threatening side-effects (DMARDs and biologic for RA come immediately to mind), but without them, we might not be able to function at all. What's one to do?

Thanks for that hard-to-answer question. As in all of medicine it is about the risk/benefit ratio.

I get it.

The dilemma is that NSAIDs work. They relieve pain, they increase mobility and they do so frequently without direct and immediate downsides. I know this, you know this, and millions others do as well.

The problem is that chronic long-term NSAID use is associated with a price. HTN, GI bleeding and potentially serious CV complications are now well documented. But these same issues are commonly encountered in the immobile. So…in severe cases of orthopedic pain flares one has to balance the pros and cons. This is where patient-centered care should be at its best: with an enlightened and non-rushed doctor and educated patient formulating a plan that is mutually agreed upon by both parties.

My point in the post is much more pedestrian than your question requires. That is, that many people believe that common OTC medicines must be innocuous. They are not–not even close. Take two other examples: Cimetidine, a drug fraught with potential drug-drug interactions, and pseudoephedrine, a common cause of arrhythmia and hypertensive crisis are easily available for mass consumption at a patient's whim. Even in this era, many doctors do not appreciate the side effects of many of these presumed innocent remedies.

Such questions on seemingly simple matters–whether to take a NSAID–illustrate the challenges of caring for patients in this era of plenty.


Dr. John, my real concern is the NSAID paediatric drops being prescibed in my jurisdiction.
I have vented over and over to the paediatricians who continue to prescibe diclofinac and NISE (not available in the USA) to children. There clearly needs to be some amplification of the serious side effects of these meds. I have long advised against any meds containing pseudoephedrine.
Dr E Williamson. Jamaica.

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