Did you know that the U.S. Food and Drug Administration Web site says drugs like ibuprofen (Advil, Motrin), Celebrex, indomethacin and diclofenac (Voltaren) can cause potentially fatal heart attacks or strokes?

The risk is usually low when using these nonster-oidal anti-inflammatory drugs, or NSAIDs, to reduce pain, redness, swelling and heat, but the risks increase with longer use or heart disease. I have no qualms about younger, healthy folks using NSAIDs for sprained ankles or painful periods, but am concerned about risk factors such as smoking, diabetes, low HDL cholesterol levels and the especially heightened danger for those with heart disease, low kidney function or prior strokes.

A fascinating observational study of coronary heart disease patients with an average age of 65 just came out in the May 2009 issue of Circulation: Cardiovascular Quality and Outcomes. Dr. Wayne Ray of Vanderbilt University and colleagues looked at 48,566 patients from three large databases — Tennessee's Medicaid program, Saskatchewan Health in Canada and a British database — and found naproxen (Aleve, Naprosyn) had better cardiovascular safety than diclofenac, ibuprofen and Celebrex, and that diclofenac increased heart attacks, strokes and deaths the most, even at doses less than 150 milligrams a day.

Several other studies also suggest that naproxen may be safer and diclofenac more hazardous. An observational study by Dr. Gunnar Gislason and others looked at complete data from Denmark and published their findings in the January 2009 issue of Archives of Internal Medicine. The study looked at 107,000 patients with chronic heart failure and likewise found naproxen safest and diclofenac the worst. In doses over 500 milligrams a day, naproxen did increase deaths, but not as much as other NSAIDs. One study in folks with coronary artery bypass graft heart surgery found increased risk after only 10 days of use, so the FDA says NSAIDs should never be used right before or after that type of surgery.

But that's not all. The FDA says NSAIDs can cause ulcers and bleeding in the stomach and intestines at any time during treatment, and that ulcers and bleeding can happen without warning symptoms and may cause death. The chance of bleeding ulcers increases with prolonged use, older age, poor health, daily use, smoking, drinking alcohol, and when taking medicines called corticosteroids and anticoagulants. Ulcer risk can be reduced (though not entirely) by taking omeprazole (Prilosec) daily. Aspirin, another NSAID, does not increase heart attacks but can cause ulcers. For pain, I like acetaminophen (Tylenol), as it does not cause heart disease or ulcers. However, per the FDA, it can cause severe liver damage if you consume three or more alcoholic drinks every day.