In patients who require high doses of a nonselective NSAID for long-term use and who have known cardiovascular disease or are at high risk for cardiovascular events. The current recommendation is to use naproxen rather than ibuprofen or diclofenac.
One should prefer naproxen to other nonselective NSAIDs, although there are few data evaluating nonselective NSAIDs other than ibuprofen and diclofenac in patients at high cardiovascular risk.
Most NSAIDs increase the risks of major cardiovascular events.
The magnitude of risk is best illustrated by a meta-analysis of data from over 300,000 participants in over 700 trials that compared nonselective NSAIDs (used at the upper end of their dose range) or coxibs with either placebo or another nonselective NSAID or coxib.
Compared with placebo, use of high-dose diclofenac or a coxib increased major cardiovascular events (nonfatal MI, nonfatal stroke, or vascular death) by 40 percent.
High-dose ibuprofen increased the risk of major coronary events but not major vascular events.
High-dose naproxen did not increase major cardiovascular events, major coronary events, or vascular death.
The estimated excess absolute risk of a major vascular event or death with use of diclofenac, coxib, and possibly ibuprofen was two events per 1000 persons per year in patients at low baseline cardiovascular risk and seven to eight events per 1000 persons per year, including two fatal events, in patients at high baseline cardiovascular risk.
Naproxen is therefore the preferred nonselective NSAID when long-term use is needed in patients at increased risk for cardiovascular disease. [Uptodate]