If you've ever taken a medication like ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn), you've taken a nonsteroidal anti-inflammatory drug (NSAID). Many NSAIDs are available over the counter (OTC). They're often used for everyday aches and pains, or to lower a fever.

But just because some NSAIDs are available OTC doesn't mean they're risk-free. Research shows that NSAIDs like ibuprofen can increase the risk of having a heart attack or stroke, especially at high doses. But how concerned should you be, really?

Do NSAIDs like ibuprofen increase your risk of heart attack?

It's possible. All NSAIDs (except aspirin) carry a warning about an increased risk of heart attack, stroke, and heart failure. And the American Heart Association (AHA) recommends using caution with NSAIDs if you have existing heart disease or you have risk factors for heart disease.

The risk for NSAIDs to cause heart damage is greater if you have existing heart problems and/or take higher NSAID doses. And the longer you use NSAIDs, the longer your risk is elevated.

However, if you don't have heart problems, and you only take NSAIDs occasionally at appropriate doses, NSAIDs are unlikely to affect your heart. Still, if you're one of the millions of people who take NSAIDs daily, it's important to understand the risks.

How do NSAIDs affect the heart?

NSAIDs work by blocking an enzyme (protein) called cyclooxygenase (COX), which lowers prostaglandin levels in the body. Prostaglandins are substances that contribute to pain and inflammation.

There are two types of COX enzymes: COX-1 and COX-2. NSAIDs can be categorized based on which COX enzyme(s) they block.

• Nonselective NSAIDS: These include ibuprofen, naproxen, and diclofenac (Cambia, Cataflam, Zipzor) and they block both COX-1 and COX-2. One downside to blocking COX-1 is a higher risk of stomach problems, including ulcers.

• Selective NSAIDs: Also called COX-2 inhibitors, these NSAIDs block COX-2 significantly more than COX-1. Examples include celecoxib (Celebrex). COX-2 inhibitors are less likely to cause stomach problems, but they may be more likely to cause heart problems.

Meloxicam is an NSAID that also blocks COX-2 more than COX-1. But it's not considered a COX-2 inhibitor.

Some research indicates that the likelihood of an NSAID causing heart problems depends on how strongly it blocks COX-2. This theory suggests that taking NSAIDs that strongly block COX-2 (like celecoxib) has a higher risk for heart problems such as heart attack compared to nonselective NSAIDs (like ibuprofen).

This may be because blocking COX-2 decreases a type of prostaglandin called prostacyclin. Prostacyclin helps keep blood vessels more open, and prevents blood clots from forming. By decreasing prostacyclin in the body, blood pressure may increase and blood clots may form, leading to heart problems.

But not all research supports this theory (more on that below). And nonselective NSAIDs like ibuprofen can also affect blood pressure, although the effects are usually small. NSAIDs can also reduce blood flow to the kidneys and cause the body to hold on to more salt and water. If this happens, your blood pressure may go up, which can affect your heart.

Which NSAID increases risk of heart attack the most?

Unfortunately, it's not clear which NSAID has the lowest risk for heart attack and other heart problems. Some studies suggest naproxen might be safest, but different studies show conflicting results:

• A 2011 review of multiple studies found that ibuprofen, diclofenac, and celecoxib increased the risk of heart attack. But naproxen didn't. All the NSAIDs studied, including naproxen, increased the risk of stroke. It's important to note that this review didn't discuss individual doses of NSAIDs. So this study doesn't tell us if typical NSAID doses have a lower risk than high doses.

• A 2013 review of over 750 studies found that diclofenac 150 mg/day and prescription-strength ibuprofen 2400 mg/day increased the risk of cardiovascular events - including heart attacks. So did taking a COX-2 inhibitor, such as celecoxib. Naproxen also didn't increase the risk of heart attacks. But all NSAIDs studied increased the risk of hospitalization for heart failure.

• A 2017 review of four studies found that all NSAIDs studied increased the risk of heart attack. This included celecoxib, along with ibuprofen, naproxen, and oral diclofenac. For all NSAIDs, higher daily doses were more risky. The risk was highest between 8 to 30 days of NSAID use, but the risk didn't increase further beyond 30 days.

The research above shows that we still can't pinpoint what makes one NSAID riskier for your heart than another. But there are some takeaways from this research that can inform NSAID best practices. Some of these include:

• How strongly an NSAID blocks COX-2 isn't the only mechanism that predicts heart risk.

• NSAIDs can increase the risk of heart problems within the first few weeks of taking them.

• Higher NSAID doses are associated with greater risk.

• The overall risk of NSAIDs causing heart problems is low.

Does aspirin increase your risk of heart problems?

No. Although aspirin is an NSAID, it works differently. It more strongly blocks COX-1 than other NSAIDs. And it blocks an enzyme called thromboxane A2 (TxA2), which is how it helps prevent blood clots.

In fact, it's recommended that people with certain heart conditions take low-dose aspirin (usually 81 mg). For example, if you've had a heart attack or stroke, low-dose aspirin is recommended to help prevent another incident.

Some people who are at high risk of heart problems should also consider taking aspirin. But always talk to a healthcare professional to see whether you're a candidate for low-dose aspirin. As with other NSAIDs, aspirin has risks of its own, including an increased risk of bleeding.

How can you protect your heart if you need to take an NSAID?

For many people, taking NSAIDs occasionally is safe. But as discussed above, there are some situations where it's riskier. To stay as safe as possible while taking an NSAID, it's a good idea to ask yourself these questions first:

• Do you have existing heart problems? If the answer is yes, don't take an NSAID without talking to a healthcare professional first. They may recommend trying another pain reliever like acetaminophen (Tylenol) first. If you do need an NSAID, naproxen is typically recommended because it's thought to have the lowest risk of causing heart problems.

• What dose should you take? Higher doses of NSAIDs are associated with greater risks to the heart. So take the lowest possible dose of your NSAID that's still effective. You can talk to your prescriber or pharmacist about what dose is best for you.

• What other health conditions do you have? NSAIDs have other risks, including stomach ulcers, bleeding, and kidney damage. So if you have a health condition that increases these risks, you may need to avoid NSAIDs altogether.

• What other medications do you take? Some medications don't mix well with NSAIDs. So you'll want to check with your pharmacist or prescriber to see if there are any potential interactions between your other medications and your NSAID. For example, NSAIDs can raise your risk of bleeding even more if you take them with blood thinners. And NSAIDs, such as ibuprofen, can increase the risk of stomach ulcers when taken with certain medications like alendronate (Fosamax).

It's also a good idea to watch for signs of heart damage if you're taking an NSAID. This may include:

• Chest pain, pressure, or tightness

• Swelling in legs, ankles, or feet

• Tiring more quickly with light exertion

• Feeling out of breath

• Racing heart or palpitations

If you experience any of these symptoms, let a healthcare professional know immediately. If they feel severe seek emergency care.

Alternatives to NSAIDs

If you or your healthcare professional prefer that you avoid NSAIDs altogether, some alternative approaches are below:

• Switch to a different kind of medication. Acetaminophen can often be used for pain or fever relief. And taking acetaminophen and an NSAID together might be another option. This may allow you to use a lower NSAID dose. But unlike NSAIDs, acetaminophen doesn't help with inflammation. And it might not be safe for everyone, such as people who frequently consume alcohol or have liver problems. Other medications may be an option for specific types of pain, too. For example, triptans like sumatriptan (Imitrex) are first-choice medications for migraines.

• Try a topical NSAID. Voltaren Arthritis pain gel, which contains diclofenac, may be a good option for you if you have joint pain. There's minimal absorption into the blood, so side effects are less likely. A prescription diclofenac skin patch (Flector) may also be an option.

• Consider non-medication approaches to manage pain. There are many approaches to managing pain that don't involve medication. Some options worth considering include physical therapy, low-impact exercise like swimming, and yoga or stretching exercises. Meditation and mindfulness practices, acupuncture, and massage therapy can also help. And if weight loss is recommended for you, this can help with pain as well.