The effect of NSAID use on emergency department visits with decompensated heart failure

Abstract

Objective

This study aimed to evaluate the association between recent nonsteroidal anti-inflammatory drug (NSAID) use and clinical presentation and in-hospital outcomes among patients presenting to the emergency department with acute decompensated heart failure.

Methods

This prospective, single-center, observational study was conducted between October 20, 2023, and May 21, 2025, in the Emergency Medicine Department of a University Hospital. A total of 400 patients diagnosed with decompensated heart failure were included. For statistical analyses, differences between patients who used NSAIDs and those who did not were compared using Pearson’s Chi-Square Test, while Fisher’s Exact Test was applied when appropriate.

Results

Among the 400 participants, 54.3% were female, and 54.0% were aged ≥ 80 years. NSAID use within the preceding 10 days was observed in 27.8% of patients. A substantial proportion of patients presented with advanced heart failure, with the majority classified as NYHA Class III or IV, and 44.0% required intensive care unit admission during hospitalization. NSAID use was more frequently observed among older patients and in those presenting with clinical features such as hypertension and tachypnea. However, no consistent or statistically significant associations were identified between recent NSAID exposure and in-hospital mortality or intensive care unit admission. These findings should be interpreted in the context of the study’s observational design and the presence of multiple clinical confounders.

Conclusion

Recent NSAID use was common among patients presenting to the emergency department with acute decompensated heart failure. In this cohort, NSAID exposure was not clearly associated with differences in in-hospital outcomes, and further analyses adjusting for clinical confounders are warranted.

Introduction

Heart failure (HF) is a clinical syndrome characterized by the inability of the heart to pump sufficient blood to meet the body’s metabolic demands due to structural or functional cardiac abnormalities. Patients typically present with symptoms such as exercise intolerance, dyspnea, orthopnea, and fatigue. They may be admitted to emergency departments (EDs) either with a chronic progressive course or with an acute decompensated clinical Picture [1].

With the global increase in the aging population, the incidence and severity of chronic diseases, including HF, have risen significantly [2–4]. The one-year mortality rate among patients diagnosed with HF is approximately 14%, whereas the five-year mortality rate reaches nearly 48%, indicating a poor long-term prognosis [2]. Several factors contribute to the development of HF, including age, gender, genetic predisposition, socioeconomic status, lifestyle, ischemic heart disease, hypertension, valvular heart disease, increased levels of proinflammatory cytokines (TNF-α, IL-1β, IL-6), metabolic disorders, and myocarditis [5–7].

Acute decompensation in HF may occur due to a variety of triggers, including newly developed myocardial infarction (MI), arrhythmias, irregular use of heart failure medications, infectious processes, dietary noncompliance, and the use of certain drugs — most notably non-steroidal anti-inflammatory drugs (NSAIDs) [8].

NSAIDs are commonly prescribed medications with analgesic, antipyretic, and anti-inflammatory effects, working through inhibition of cyclooxygenase (COX) enzymes that control prostaglandin production [9, 10]. They are often used to treat various conditions, such as osteoarthritis, rheumatoid arthritis, acute musculoskeletal injuries, dysmenorrhea, and gout attacks [11]. However, NSAIDs are associated with significant side effects, including gastrointestinal issues [12], kidney injury [13], heart attacks, ischemic cerebrovascular events, worsening of heart failure, and high blood pressure. The likelihood of these issues rises considerably in people with existing cardiovascular disease [14].

NSAIDs may exacerbate HF by multiple mechanisms, such as inhibition of renal prostaglandin synthesis, leading to reduced renal perfusion, sodium and water retention, resulting in increased cardiac workload, worsening hypertension control, and triggering myocardial dysfunction. These pathophysiological effects may further destabilize patients already presenting with HF [15–19].

This study aimed to evaluate the association between recent nonsteroidal anti-inflammatory drug use and clinical characteristics and in-hospital outcomes among patients presenting to the emergency department with acute decompensated heart failure.

Methods

Study design and setting

The study, “The effect of NSAID use on emergency department visits with decompensated heart,” was designed as a prospective observational investigation and conducted at the Emergency Medicine Clinic of Göztepe Prof. Dr. Süleyman Yalçın City Hospital, an academic tertiary care center affiliated with Istanbul Medeniyet University. The study period extended from October 20, 2023, to May 21, 2025.

The study received approval from the Clinical Research Ethics Committee at Istanbul Medeniyet University Prof. Dr. Süleyman Yalçın City Hospital (Approval No: 2023/0688; Date: October 11, 2023). The research was carried out in full accordance with the principles outlined in the Declaration of Helsinki and its subsequent revisions.

The main goal of this study was to assess whether nonsteroidal anti-inflammatory drug (NSAID) use in the last 10 days is associated with the presence and clinical severity of acute decompensated heart failure (ADHF) in patients arriving at the emergency department.

Study population and sample

Göztepe Prof. Dr. Süleyman Yalçın City Hospital is a high-volume tertiary academic hospital with an annual emergency department census of approximately 400,000 visits. The adult emergency department is fully equipped to manage critically ill patients and provides comprehensive evaluation and treatment for cardiovascular emergencies.

All patients aged ≥ 18 years who presented to the emergency department during the study period with clinical findings of ADHF, and whose diagnoses were subsequently confirmed after initial emergency interventions, were considered eligible for inclusion in the study.

Acute decompensated heart failure (ADHF)

Acute decompensated heart failure was defined as a rapid onset or worsening of symptoms and signs of heart failure requiring emergency department presentation, accompanied by at least one of the following: pulmonary congestion on chest radiography, elevated natriuretic peptide levels, objective evidence of volume overload on physical examination, or supportive findings on transthoracic echocardiography or bedside cardiac ultrasound when available, in patients with known or newly diagnosed heart failure. Cardiogenic shock and hypertensive pulmonary edema were considered clinical presentations within the spectrum of acute decompensated heart failure.

Inclusion criteria

• Adults aged 18 years and older.

• Presentation to the emergency department with a primary diagnosis of acute decompensated heart failure.

• Diagnosis of ADHF based on predefined clinical, laboratory, and imaging criteria.

• Availability of documented medication history confirming physician-prescribed NSAID use or non-use within the preceding 10 days.

Exclusion criteria

• Patients with acute coronary syndrome as the primary diagnosis.

• Patients with end-stage renal disease requiring chronic dialysis.

• Patients with missing or unreliable medication history.

• Repeat emergency department visits by the same patient during the study period (only the first visit was included).

Patient enrollment

All eligible patients were prospectively screened during the study period. Patients were enrolled consecutively after confirmation of acute decompensated heart failure and assessment of medication history. Patients who met predefined exclusion criteria or had incomplete evaluation were excluded. A flow diagram summarizing patient screening, exclusions, and final inclusion is provided in Fig. 1.

Fig. 1.

Flow diagram of patient selection

Definition of recent NSAID use

Recent NSAID use was defined as the use of a nonsteroidal anti-inflammatory drug within 10 days prior to emergency department presentation. Only NSAIDs prescribed by a physician were considered, and exposure was confirmed based on patient self-report, indicating actual use of the prescribed medication. Over-the-counter NSAID use was not included in the exposure definition. The 10-day exposure window was selected to capture recent short-term NSAID use temporally relevant to emergency department presentation and acute clinical status.

Study outcomes

The primary outcome of the study was in-hospital mortality. Secondary outcomes included admission to the intensive care unit, length of hospital stay, and disposition from the emergency department (ward admission or discharge). All outcomes were assessed during the index hospitalization, and deaths occurred during in-hospital follow-up after emergency department admission.

Data collection

Patient information was obtained from:

• Structured case report forms were prepared for the study.

• Hospital electronic medical records (NUCLEUS automation system).

• Epicrisis notes and consultation reports.

• Laboratory and imaging data.

  All data were recorded in a standardized database for further statistical analysis.

Variables and Parameters Collected were

• Demographic data,

• Clinical status at presentation (Cardiogenic shock, Hypertensive or hypotensive pulmonary edema, decompensated heart failure),

• Diagnostic findings (previously known vs. newly diagnosed heart failure, NYHA functional classification, Left Ventricular Ejection fraction (EF)),

• NSAID exposure (NSAID use within the last 10 days before presentation),

• Comorbidities and contributing factors (infection, arrhythmias, anemia, recent myocardial infarction (MI), chronic kidney disease (CKD), acute kidney injury (AKI), valvular dysfunction, medication or dietary noncompliance),

• Clinical outcomes (discharge from the ED, admission to inpatient wards, ıntensive care unit (ıcu) admission, ın-hospital mortality),

Statistical analysis

Continuous variables were summarized as mean ± standard deviation or median (interquartile range), as appropriate. Comparisons between patients with and without recent NSAID use were performed using the Student’s t-test or the Mann–Whitney U test for continuous variables, and the chi-square test or Fisher’s exact test for categorical variables.

To explore the association between recent NSAID use and in-hospital outcomes, exploratory multivariable logistic regression analyses were planned. Clinically relevant covariates were selected a priori (e.g., age, sex, baseline renal function, blood pressure at presentation, and relevant comorbidities). Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). A two-sided p-value < 0.05 was considered statistically significant. However, given the study’s observational design and the limited number of outcome events, fully adjusted multivariable models were not presented to avoid overfitting.

Results

When evaluating the demographic characteristics of the study group, 54.0% of participants were aged ≥ 80 years, and 54.3% were female. Decompensated heart failure was the primary presentation at admission, and 3.5% of patients were identified as being in cardiogenic shock at initial evaluation. Nearly half of the cohort (47.5%) consisted of patients with newly diagnosed heart failure. All patients with newly diagnosed heart failure were enrolled only if they presented with acute decompensated heart failure at the time of emergency department admission. According to the New York Heart Association (NYHA) functional classification, most patients were classified as Class III or IV. Fifty-three patients (13.3%) experienced an acute myocardial infarction during presentation. The most frequently reported comorbid conditions were infection (24.0%) and anemia (24.3%).

Ninety-three patients (23.3%) were noncompliant with dietary recommendations, and 94 patients (23.5%) reported irregular adherence to prescribed medications. Recent NSAID use within the preceding 10 days was reported by 111 patients (27.8%). At initial evaluation, the majority of patients were normotensive (57.3%). On electrocardiography, normal sinus rhythm (58.8%) and atrial fibrillation (38.3%) were the most frequently observed rhythms. Tachypnea was present in 68.8% of patients at presentation.

During the study period, 23.3% of patients were discharged from the emergency department, 27.3% were admitted to hospital wards, 44.0% required intensive care unit admission, and 5.5% died during hospitalization. Detailed information regarding participants’ age and sex distribution, acute presentation, NYHA classification, medical history, dietary and medication noncompliance, NSAID use, blood pressure status, electrocardiographic findings, myocardial infarction history, and clinical outcomes is summarized in Table 1.

Table 1.

Participants’ age and gender distribution, current status, NYHA classification, disease history, diet and medication non-compliance, NSAID use, blood pressure, ECG findings and MI history

	N (%)
Age
45–64	44 (11,0)
65–79	138 (34,5)
> 80	216 (54,0)
Cender
Female	217 (54,3)
Male	183 (45,8)
Instant blood pressure
Hypertensive	158 (39,4)
Hypotensive	229 (57,3)
Normotensive	13 (3,3)
Diagnosis
With known diagnosed DHF	210 (52,5)
New diagnosed DHF	190 (47,5)
NYHA classification
Class 1	3 (0,8)
Class 2	60 (15,0)
Class 3	142 (35,5)
Class 4	195 (48,8)
Disease history
Infection	96 (24,0)
Anemia	59 (14,8)
Dysrhytmhia	97 (24,3)
Chronic kidney injury (CKI)	60 (15,0)
Acute kidney injury (AKI)	9 (2,3)
New cardiac valve dysfunction	63 (15,8)
Electrocardiography (ECG) findings
Tachycardia	79 (19,8)
Ventricular tachycardia (VT)	3 (0,8)
Supraventricular tachycardia (SVT)	2 (0,5)
Atrial fibrillation (AF)	156 (39,0)
Normal sinus rhyhtm (NSR)	235 (59,8)
Bradycardia	10 (2,5)
Dietry noncompliance	93 (23,3)
Drug noncompliance	94 (23,6)
NSAİD use	111 (27,8)
New myocardial infarction (MI)	53 (13,3)
Cardiogenic shock	14 (3,5)
Tachypnea	275 (68,8)
Outcome
Discharged	93 (23,3)
Admission to the ward	109 (27,3)
Admission to the ICU	176 (44,0)
Exitus	22 (5,5)

NSAID use was more frequently observed among patients aged ≥ 80 years, male patients, those presenting with hypertensive decompensated heart failure, patients with a prior diagnosis of heart failure, and those classified as NYHA Class III or IV. In addition, NSAID use was more frequently observed among patients with a history of infection or anemia, those presenting with elevated blood pressure or tachypnea, patients with normal sinus rhythm or atrial fibrillation on electrocardiography, those with an ejection fraction greater than 50% or less than 40%, and patients requiring intensive care unit admission.

NSAID use differed significantly according to blood pressure status and the presence of tachypnea at presentation. The associations between NSAID use and patients’ age, sex, acute clinical status, diagnostic categories, NYHA functional class, medical history, blood pressure, electrocardiographic findings, ejection fraction, occurrence of acute myocardial infarction, dietary and medication noncompliance, and clinical outcomes are summarized in Table 2.

Table 2.

The relationship between NSAID use and patients’ age, gender, current status, diagnosis, NYHA classification, disease history, blood pressure, and ECG findings, EF, new MI development, diet and medication non-compliance, and outcome

	NSAID use
	Yes	No	P
*Age			0,792*
30–44	1 (50,0)	1 (50,0)
45–64	13 (29,5)	31 (70,5)
65–79	39 (28,3)	99 (71,7)
80+	58 (26,9)	158 (73,1)
*Gender
Female	58 (26,7)	159 (73,3)	0,619
Male	53 (29,0)	130 (71,0)
Diagnosis
With known diagnosed DHF  New diagnosed DHF	62 (29,5) 49 (25,8)	148 (70,5) 141 (74,2)	0,405
NYHA classification
Class 1  Class 2  Class 3  Class 4	1 (33,3) 9 (15,0) 43 (30,3) 58 (29,7)	2 (66,7) 51 (85,0) 99 (69,7) 137 (70,3)	0,087*
Disease history
Infection  Anemia  Dysrhytmhia  Chronic kidney injury (CKI)  Acute kidney injury (AKI)  New cardiac valve dysfunction	32 (33,3) 25 (25,8) 17 (28,8) 12 (20,0) 3 (33,3) 14 (22,2)	64 (66,7) 72 (74,2) 42 (71,2) 48 (80,0) 6 (66,7) 49 (77,8)	0,161 0,617 0,843 0,146 0,713* 0,286
Electrocardiography (ECG) findings
Tachycardia  Ventricular tachycardia (VT)  Supraventricular tachycardia (SVT)  Atrial fibrillation (AF)  Normal sinus rhyhtm (NSR)  Bradycardia	28 (35,4) 2 (66,7) 1 (50,0) 38 (24,8) 66 (28,1) 4 (40,0)	51 (64,6) 1 (33,3) 1 (50,0) 115 (75,2) 169 (71,9) 6 (60,0)	0,088 0,188* 0,478* 0,306 0,858 0,474*
Instant blood pressure
Hypertensive  Hypotensive  Normotensive	57 (36,1) 3 (23,1) 51 (22,3)	101 (63,9) 10 (76,9) 178 (77,7)	0,003 0,702 0,005
Ejectiton Fraction (EF of left ventricle)
< 40%  40%-49%  > 50%	40 (31,0) 15 (26,8) 56 (26,0)	89 (69,0) 41 (73,2) 159 (74,0)	0,600
Outcome
Discharged  Admission to the ward  Admission to the ICU  Exitus	18 (19,4) 32 (29,4) 55 (31,3) 6 (27,3)	75 (80,6) 77 (70,6) 121 68,8) 16 (72,7)	0,213
New myocard infaction (MI)	12 (22,6)	41 (77,4)	0,373
Dietry noncompliance	27 (29,0)	66 (71,0)	0,753
Drug noncompliance	31 (33,0)	63 (67,0)	0,196
Cardiogenic shock	4 (28,6)	10 (71,4)	0,090
Tachypnea	86 (31,3)	189 (68,7)	0,020

* Fisher’s Exact Test was used when expected cell counts were < 5

NSR: Normal sinus rhythm, EF, ejection fraction, MI, myocardial infarction

Discussion

In our study, physician-prescribed NSAID use was common among patients presenting to the emergency department with ADHF. However, no clear association was demonstrated between NSAID exposure and in-hospital clinical outcomes in this cohort. Findings regarding NSAID use in patients with HF have been heterogeneous. Some studies have reported associations with increased congestion, worsening renal function, and adverse clinical outcomes, whereas others have not identified a consistent effect on short-term in-hospital outcomes [20–22]. Differences in study populations, definitions of NSAID exposure, and selected outcome measures may partly explain these discrepancies. Epidemiological data also indicate that HF prevalence increases markedly in individuals aged 80 years and older, and that advanced functional impairment is common among patients presenting with ADHF [20]. Given the observational design of our study, the findings reflect associations rather than causal relationships.

Approximately half of the included patients had a history of CKD and anemia. These conditions are common comorbidities in HF and have been associated with adverse clinical outcomes. Previous cohort studies have shown that CKD is linked to higher hospitalization and mortality rates in patients with HF [23]. In addition, a substantial proportion of patients had a history of infection. Infection is recognized as an important trigger of acute decompensation in HF and has been associated with increased risks of sepsis and mortality [18, 22]. Moreover, anemia and arrhythmias may contribute to HF progression by impairing myocardial oxygen delivery [18].

In our study, approximately one-third of patients demonstrated poor adherence to HF therapy, highlighting the challenges of long-term disease management. Treatment non-adherence in HF has been associated with factors such as forgetfulness, concerns about adverse effects, and limited health literacy [24]. Large observational studies and meta-analyses have shown that non-adherence is associated with increased hospitalization and mortality in HF [25]. Studies from different healthcare systems have also reported that post-discharge medication non-adherence is common and may be associated with higher readmission rates [26]. These findings suggest that poor treatment adherence is an important and potentially modifiable factor in the clinical course of HF.

Previous studies have reported NSAID use rates between 2% and 8% in patients with HF. In the United Kingdom, NSAID use was reported at 8 per 1,000 patients [27], whereas in the United States, the prevalence was 8.5% [28]. In our study, the NSAID use rate was higher. This difference may be attributable to variations in patient characteristics, exposure definitions, access to healthcare, and prescribing practices. These findings indicate that NSAID use remains clinically relevant in patients with HF and should be carefully evaluated.

Among patients presenting to our emergency department with HF, tachypnea and hypertension were the most frequent clinical findings. These features are commonly described in guidelines and observational studies as typical presentations of ADHF [18]. Atrial fibrillation was also observed in a substantial proportion of patients. The close relationship between atrial fibrillation and HF has been emphasized in the literature, and their coexistence may increase symptom burden and clinical complexity [29]. These findings underscore the heterogeneous clinical presentation and multifactorial pathophysiology of HF in the emergency setting.

Multicenter observational studies have reported ICU admission rates ranging from 30% to 50% among patients presenting to the emergency department with HF, and a subset of these patients require invasive support [30]. In-hospital mortality in HF has been reported at approximately 6%, with a higher risk in older patients and those with impaired cardiac function [20]. The ICU admission and in-hospital mortality rates observed in our study were consistent with previously reported ranges.

When NSAID use was analyzed according to sex and age groups, no statistically significant differences were identified. NSAID use rates were similar between women and men, consistent with studies reporting no clear association between sex and NSAID use [31, 32]. Although NSAID use appeared numerically higher in some age groups, these differences were not statistically significant. Higher NSAID use was also observed among patients presenting with hypertensive HF and cardiogenic shock; however, these findings did not reach statistical significance and should be interpreted cautiously.

Large observational cohorts and meta-analyses have reported that NSAID exposure is associated with increased HF-related hospitalizations, potentially mediated by fluid retention and impaired cardiac function [33–35]. More severe clinical presentations and higher ICU utilization have also been described among HF patients exposed to NSAIDs [21]. In our study, cardiogenic shock was more frequent among NSAID users; however, given the exploratory nature of the analysis, this finding should be interpreted with caution. Epidemiological studies have also reported an association between NSAID use and myocardial infarction (MI) in patients with HF [36]. In our cohort, no significant difference in NSAID use was observed between patients with and without recent MI. Overall, these findings indicate that the relationship between NSAID exposure and cardiovascular risk in HF is complex.

NSAIDs, particularly selective cyclooxygenase-2 inhibitors, have been associated with an imbalance between prostaglandin I₂ and thromboxane A₂, potentially leading to platelet activation, endothelial dysfunction, and vasoconstriction [33, 36, 37]. These mechanisms may contribute to a prothrombotic state. Several large observational studies and meta-analyses have shown that the increased risk of MI associated with NSAID use may be more pronounced shortly after treatment initiation, especially with selective COX-2 inhibitors and agents such as diclofenac [38, 39]. In patients with HF, NSAID exposure has also been associated with increased risk of adverse cardiovascular events, particularly in the presence of comorbidities such as hypertension and diabetes mellitus [40, 41]. Recent studies have highlighted that simple prognostic indices derived from routine clinical parameters may help predict outcomes in patients presenting with ADHF. Akça et al. [42] and Özkan et al. [43] demonstrated that the blood urea nitrogen–to–left ventricular ejection fraction ratio reflects cardiorenal dysfunction and is associated with mortality. Given the adverse effects of NSAIDs on renal perfusion and sodium–water balance, these findings further emphasize the clinical relevance of NSAID use. Collectively, these data suggest that NSAID use may contribute to worse outcomes through inflammatory and cardiorenal mechanisms.

No statistically significant differences in NSAID use were observed across subgroups defined by comorbid disease history. Due to the known effects of NSAIDs on renal perfusion, their use in patients with CKD or acute kidney injury has long been a clinical concern. Although NSAID use appeared lower among patients with CKD in our cohort, this finding should be interpreted cautiously. Current international guidelines, including those from the American Heart Association, recommend avoiding NSAID use in patients with HF and concomitant CKD [8, 44]. These recommendations provide important context for interpreting prescribing patterns.

NSAID use was more frequent among patients with a history of infection. A systematic review by Eichacker et al. reported that NSAID use may mask infectious symptoms and delay the recognition of sepsis, potentially leading to worse outcomes [45]. These findings underscore the importance of careful evaluation of NSAID exposure, particularly in HF patients with multiple comorbidities.

NSAID use was also observed in patients with anemia and cardiac arrhythmias. NSAID exposure has been associated with hematologic toxicity and gastrointestinal adverse effects that may contribute to anemia and negatively affect cardiovascular status [46]. Previous studies have suggested that NSAID exposure, especially in older adults, may be associated with increased arrhythmic risk, potentially mediated by electrolyte disturbances or other mechanisms. Ntalarizou et al. reported an association between NSAID use and atrial fibrillation [47]. Increased arrhythmic risk following NSAID exposure in the post-MI setting has also been described [48]. These findings support cautious evaluation of NSAID use in HF patients with coexisting anemia or arrhythmias.

In our study, NSAID use was observed among patients who were non-adherent to prescribed HF therapy and dietary recommendations. Although these associations were not statistically significant, they suggest a potential overlap between poor adherence and NSAID exposure in chronic HF. Treatment non-adherence in older adults is multifactorial and may be influenced by polypharmacy and symptom-oriented medication use [24, 49]. NSAID use may increase treatment complexity and indirectly contribute to reduced adherence, particularly in elderly patients with multiple comorbidities. Further prospective studies are needed to clarify this relationship.

In this cohort, NSAID use was associated with clinical features such as hypertension and tachypnea. These findings may reflect hemodynamic effects related to NSAID exposure, including fluid retention and changes in vascular tone, as emphasized in previous studies [50, 51]. Atrial fibrillation was the most common arrhythmia among NSAID users. Although causal inference cannot be made, prior studies have reported an increased arrhythmic risk associated with NSAID exposure, particularly in older populations [52].

Limitations

This study has several limitations that should be considered when interpreting the findings. First, it was conducted at a single center with a limited geographic scope and included a relatively small sample size of 400 patients, which may limit generalizability. Second, the study period was limited, and recent NSAID exposure was assessed as a composite variable rather than stratified by specific agents or drug subclasses.

Third, NSAID use was determined based on patient self-report and prescription records, which may be subject to recall bias or misclassification. In addition, outcomes were not analyzed by NSAID dose, exposure duration, or potential interactions with concomitant medications. Finally, because this is an observational study, causal inferences cannot be established. Future multicenter studies with larger sample sizes and more detailed exposure assessment are warranted to further clarify the relationship between NSAID use and clinical outcomes in patients with acute decompensated heart failure. Although multivariable analyses could further clarify independent associations, residual confounding cannot be excluded, and the results should be interpreted cautiously. Detailed classification of atrial fibrillation subtypes and the applicability of the NYHA functional classification in the acute emergency department setting represent additional limitations of this study. In addition, the definition of recent NSAID exposure used a fixed 10-day window and did not account for differences in dosage, duration, or specific NSAIDs, which may have influenced the observed associations. Information on specific NSAID subtypes, dosages, and durations of use was unavailable and therefore could not be analyzed.

Conclusion and recommendations

In this cohort of patients presenting to the emergency department with acute decompensated heart failure, recent physician-prescribed NSAID use was common. Although no statistically significant associations were observed between NSAID use and in-hospital mortality or intensive care unit admission, NSAID exposure was more frequently observed in patients with a higher symptom burden, including hypertension and tachypnea. These findings should be interpreted cautiously, given the observational nature of the study. Differences between the present results and those of prior studies may reflect variability in study populations, exposure definitions, and methodological approaches. From a clinical perspective, NSAID use in patients with heart failure warrants careful consideration. When NSAID therapy is deemed necessary, close monitoring of renal function, blood pressure, electrolyte balance, and volume status may be prudent. In patients at higher risk of decompensation—such as older adults or those with chronic kidney disease, active infection, or multiple comorbidities—alternative analgesic strategies should be considered. In addition, assessment of treatment adherence and patient education regarding the potential risks of NSAID use remain important components of comprehensive heart failure management.

Author contributions

Conception or design of the work | Kevser Simbil, Behcet Al Data collection | Kevser Simbil, Behcet Al, Turab Sami Alatay Data analysis and interpretation | Kevser Simbil, Behcet Al, Halil Emre Bilgic Drafting the article | Kevser Simbil, Behcet Al, Turab Sami Alatay Critical revision of the article | Kevser Simbil, Behcet Al, Halil Emre Bilgic Final approval of the version to be published | Kevser Simbil, Behcet Al, Turab Sami Alatay.

Funding

This study did not receive any specific funding.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study received approval from the Clinical Research Ethics Committee at Istanbul Medeniyet University Prof. Dr. Süleyman Yalçın City Hospital (Approval No: 2023/0688; Date: October 11, 2023). The research was carried out in full accordance with the principles outlined in the Declaration of Helsinki and its subsequent revisions.

Informed consent

was obtained from all participants or their legal guardians.

Competing interests

The authors declare no competing interests.