Association between nonsteroidal anti-inflammatory drugs and atrial fibrillation among a middle-aged population: a nationwide population-based cohort

Atrial fibrillation and breast cancer—Vicious twins? A systematic review and meta-analysis

Background

Epidemiological studies suggest a bidirectional association between atrial fibrillation and breast cancer. This study aimed to conduct a meta-analysis to elucidate the prevalence of atrial fibrillation among breast cancer patients, and the bidirectional association between atrial fibrillation and breast cancer.

Methods

PubMed, the Cochrane Library, and Embase were searched to identify studies reporting the prevalence, incidence, and bidirectional association between atrial fibrillation and breast cancer. The study was registered with PROSPERO (CRD42022313251). Levels of evidence and recommendations were assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

Twenty-three studies (17 retrospective cohort studies, 5 case-control studies and 1 cross-sectional study) involving 8,537,551 participants were included. Among patients with breast cancer, the prevalence of atrial fibrillation was 3% (11 studies; 95% CI: 0.6 to 7.1%) and the incidence was 2.7% (6 studies; 95% CI: 1.1 to 4.9%). Breast cancer was associated with increased risk of atrial fibrillation (5 studies; hazard ratio [HR]: 1.43, 95% CI: 1.12 to 1.82, I2 = 98%). Atrial fibrillation was also significantly associated elevated risk of breast cancer (5 studies HR: 1.18, 95% CI: 1.14 to 1.22, I2 = 0%). Grade assessment shown low certainty of the evidence for the risk of atrial fibrillation and moderate certainty of the evidence for the risk of breast cancer.

Conclusion

Atrial fibrillation is not uncommon in patients with breast cancer and vice versa. There is a bidirectional association between atrial fibrillation (low certainty) and breast cancer (moderate certainty).

Cancer and atrial fibrillation: Epidemiology, mechanisms, and anticoagulation treatment

Cancer patients are at an increased risk of developing atrial fibrillation (AF) and thrombosis. However, the management of anticoagulation in patients with both diseases may be challenging, and data on these patients are lacking. We summarize the current evidence on the incidence and prevalence of cancer in AF and vice versa and provide some practical considerations on the management of oral anticoagulation in specific clinical situations. Low-molecular weight heparins are not approved for thromboprophylaxis in AF, and management of warfarin can be difficult. The use of direct oral anticoagulants may be particularly attractive for their rapid onset/offset action and lower bleeding risk.

Opioid, gabapentinoid, and nonsteroidal anti-inflammatory medication use and the risks of atrial fibrillation and supraventricular ectopy in the Multi-Ethnic Study of Atherosclerosis

PURPOSE

Opioids, gabapentinoids, and nonsteroidal anti-inflammatory drugs (NSAIDs) may have adverse cardiovascular effects. We evaluated whether these medications were associated with incident clinically detected atrial fibrillation (AF) or monitor-detected supraventricular ectopy (SVE), including premature atrial contractions (PACs) and supraventricular tachycardia (SVT).

METHODS

We used data from the Multi-Ethnic Study of Atherosclerosis (MESA), a cohort study that enrolled 6814 Americans without clinically detected cardiovascular disease in 2000 to 2002. At the 2016 to 2018 examination, 1557 individuals received ambulatory electrocardiographic (ECG) monitoring. Longitudinal analyses investigated time-varying medication exposures at the first five exams (through 2011) in relation to incident clinically detected AF through 2015 using Cox proportional hazards regression models. Cross-sectional analyses investigated medication exposures at 2016 to 2018 examination and the risk of monitor-detected SVE using linear regression models.

RESULTS

The longitudinal cohort included 6652 participants. During 12.4 years of mean follow-up, 982 participants (14.7%) experienced incident clinically detected AF. Use of opioids, gabapentinoids, and NSAIDs were not associated with incident AF. The cross-sectional analysis included 1435 participants with ECG monitoring. Gabapentinoid use was associated with an 84% greater average frequency of PACs/hour (95% CI, 25%-171%) and a 44% greater average number of runs of SVT/day (95% CI, 3%-100%). No associations were found with use of opioids or NSAIDs in cross-sectional analyses.

CONCLUSIONS

In this study, gabapentinoid use was associated with SVE. Given the rapid increase in gabapentinoid use, additional studies are needed to clarify whether these medications cause cardiovascular complications.

Ethnic inequality in non-steroidal anti-inflammatory drug-associated harm in New Zealand: A national population-based cohort study

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with many serious complications and they are widely used in New Zealand (NZ). However, differences in NSAID-associated risk for these complications between ethnic groups are largely unknown. We assessed ethnic disparities in risk of hospital admission for upper gastrointestinal bleeding (UGIB), heart failure, and acute kidney failure (AKF) in NZ's primary care population prescribed and dispensed NSAIDs.

METHODS

Retrospective cohort study utilising national pharmaceutical dispensing and hospital admissions data 2007 to 2015. Patient follow-up included 90-day periods following the dispensing of NSAIDs. Risk for each adverse outcome in Maori, Pacific, European, and Asian patients was estimated using multivariable Poisson regression adjusting for age, sex, deprivation, comorbidity and concurrent drug use.

RESULTS

3 023 067 patients were dispensed NSAIDs between 2008 and 2015. Their total intended duration of NSAID treatment encompassed 2 353 140 patient-years. Maori, Pacific and Asian patients were younger than European patients (all P < .001). After adjusting for other risk factors, Maori (rate ratio: 2.54, 95% confidence interval: 2.23-2.90) and Pacific patients (3.17, 2.69-3.74) were more likely to be hospitalised for UGIB than Europeans (reference), and heart failure (Maori: 2.48, 2.24-2.74; Pacific: 1.97, 1.69-2.30). Risk of AKF was higher in Maori (1.46, 1.23-1.74). Higher risk for UGIB and HF in Maori and Pacific patients was most pronounced in males and patients aged <60 years.

CONCLUSIONS

Inequalities exist in the incidence of serious adverse outcomes experienced by different ethnic groups in NZ while using NSAIDs. Interventions to promote safer use of these medicines are required to reduce this inequity.

Nonsteroidal anti-inflammatory drugs and incidence of atrial fibrillation: a meta-analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for many inflammatory disorders and pain-related illnesses. Despite their widespread use, the association between NSAIDs and the incidence of atrial fibrillation (AF) remains unclear. The aim of this systematic review and meta-analysis is to investigate this association.

METHODS

A systematic review was conducted in MEDLINE, EMBASE and Cochrane databases from inception through August 2019 to identify studies that evaluated the risk of AF among patients using NSAIDs. Pooled risk ratios (RRs) and 95% CI were calculated using a random-effect, generic inverse variance method. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42019141609).

RESULTS

Eight observational studies (four case-control studies and four cohort studies) with a total of 14 806 420 patients were enrolled. When compared with nonNSAIDs users, the pooled RR of AF in patients with NSAIDs use was 1.29 (95% CI 1.19-1.39). Meta-analyses based on the type of study were additionally performed. Subgroup analysis by study design revealed a significant association between the use of NSAIDs and AF for both case-control studies (pooled RR 1.37; 95% CI, 1.15-1.63) and cohort studies (pooled RR 1.22; 95% CI, 1.14-1.31). Sub-analyses based on specific NSAIDs showed pooled RRs of AF in patients using ibuprofen of 1.30 (95% CI 1.22-1.39), naproxen of 1.44 (95% CI 1.18-1.76) and diclofenac of 1.37 (95% CI 1.10-1.71), respectively. Funnel plot and Egger's regression asymmetry tests were performed and showed no publication bias.

CONCLUSION

NSAID use is associated with incident AF. Our study also demonstrated a consistent result among different NSAIDs.

Cardiovascular Risk of Nonsteroidal Anti-inflammatory Drugs and Classical and Selective Cyclooxygenase-2 Inhibitors: A Meta-analysis of Observational Studies

The purpose of this study was to review the published evidence on the clinical use of nonsteroidal anti-inflammatory drugs (NSAIDs) and to assess the cardiovascular risk (CVR) of cyclooxygenase-2 inhibitors (coxibs), excluding aspirin, by means of a meta-analytic procedure. A search was conducted on MEDLINE and EMBASE databases between October 1999 and June 2018. Cohort and case-control studies showing CVR as relative risk (RR), odds ratio, hazard ratio, or incidence rate ratio associated with NSAIDs versus no treatment were selected. We estimated the pooled RR and the 95% confidence interval (CI) for all NSAIDs as a whole and individually. Eighty-seven studies met the inclusion criteria. Overall, NSAIDs were found to be associated with a statistically significantly increased CVR (RR, 1.24 [95%CI, 1.19-1.28]). The risk was slightly higher for coxibs (RR, 1.22 [95%CI, 1.17-1.28]) as compared with nonselective NSAIDs (RR, 1.18 [95%CI, 1.12-1.24]). Data analysis by drug disclosed that rofecoxib (RR, 1.39 [95%CI, 1.31-1.47]), followed by diclofenac (RR, 1.34 [95%CI, 1.26-1.42]) and etoricoxib (RR, 1.27 [95%CI, 1.12-1.43]) were the NSAIDs associated with the highest CVR. Analysis by type of event showed that the highest risk corresponded to vascular events for both coxibs (RR, 2.18 [95%CI, 1.72-2.78]) and nonselective NSAIDs (RR, 2.46 [95%CI, 2.00-3.02]). The meta-analysis results suggest that the use of the marketed coxibs celecoxib and etoricoxib would be related to a statistically significant CVR increase. Etoricoxib CVR could be higher than that for celecoxib. This increment would be similar to classical NSAID CVR.

Association between nonsteroidal anti-inflammatory drugs and atrial fibrillation among a middle-aged population: a nationwide population-based cohort

AIMS

It remains inconclusive whether the use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk of atrial fibrillation (AF), especially in middle-aged Asian populations. In this study, we evaluated the association between NSAID use and the risk of AF in a nationwide population-based study of middle-aged individuals in Taiwan.

METHODS

A nested case-control study was conducted using the National Health Insurance Research Database (NHIRD) in Taiwan. We identified the cases with a diagnosis of AF (ICD-9-CM codes: 427.31) and the matched controls from three independent Longitudinal Health Insurance Databases (LHIDs) derived from the NHIRD from data collected from 2001 to 2013. Conditional logistic regression models with covariate adjustment were performed to evaluate the association between NSAID use and the risk of AF.

RESULTS

A total of 57 058 participants (28 529 AF cases and 28 529 matched controls) were included. Participants with NSAID use had an elevated risk of AF compared to non-users [adjusted odds ratio (AOR) = 1.18, 95% confidence interval (CI): 1.14-1.23]. When further assessing the effects of different classes of NSAIDs on the risk of AF, the results showed that participants who used non-selective NSAIDs had a significantly elevated risk of AF (AOR = 1.18, 95% CI: 1.13-1.23), as did participants with a combined use of selective and non-selective NSAIDs (AOR = 1.30, 95% CI: 1.21-1.39).

CONCLUSIONS

NSAID use was associated with an increased risk of AF occurrence among the participants included in our study cohort. Closely monitoring the adverse effects of NSAID treatment on the risk of AF will be important, particularly among individuals at high risk.