Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most popular drugs in the pharmacy. That’s because there is a lot of pain out there. Whether it’s from headaches, arthritis or backaches, tens of millions of people seek relief with OTC analgesics such as Advil, Aleve, Motrin IB, Excedrin or Tylenol. There are data suggesting that NSAIDs can raise blood pressure in susceptible people. Will a non-NSAID drug like acetaminophen raise blood pressure? Many people “trust Tylenol.” They believe that acetaminophen (APAP) is one of the safest drugs in the pharmacy. What are some hidden dangers for the heart?
APAP and the Heart:
People with heart conditions are often advised to avoid nonsteroidal anti-inflammatory drugs. Such drugs have been linked to high blood pressure, fluid retention, atrial fibrillation and even heart attacks. That’s why health care professionals often recommend acetaminophen as an alternative to NSAIDs.
A new study presented at the American Physiology Summit meetings suggests that the advice may be misplaced. The scientists utilized a mouse model and discovered that acetaminophen altered over 20 signaling pathways in the heart. Because this research was conducted in mice, clinical trials will be necessary to verify the impact of acetaminophen on the human heart.
Here’s how the American Physiological Society describes the new research (April 5, 2024):
“‘We found that regular use of acetaminophen at concentrations that are considered safe—equivalent to 500 mg/day—causes numerous signaling pathways inside the heart to be altered,’ said Gabriela Rivera, the study’s first author…”
“The results suggest that long-term medium- to high-dose acetaminophen use could cause heart issues as a result of oxidative stress or the buildup of toxins that are produced as acetaminophen breaks down, Rivera said. While our bodies can usually clear such toxins before they cause damage, it may be harder for the body to keep up when medium- to high- doses are taken consistently over time.”
This Reader Wants to Know if Acetaminophen Will Raise Blood Pressure:
Q. I have taken NSAIDs for pain relief, but they bump up my blood pressure. When I had some dental work done, I took Advil for the throbbing pain. When I checked my blood pressure, it had spiked about 40 points over my usual number.
Is Tylenol less likely to be a problem? I try to avoid pain meds as much as possible, but occasionally I have to take something.
NSAIDs and Hypertension:
A. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB) or naproxen (Aleve) can raise blood pressure (European Heart Journal, Nov. 11, 2017). The authors of this research note that 70 million prescriptions for NSAIDs are filled each year in the US. If you add in OTC use of these pain relievers, you end up with 30 billion doses taken every year just in America. That’s almost 100 doses for every man, woman and child annually.
Here are the results of this double-blind, randomized, clinical trial:
“The percentage of patients with normal baseline BP who developed hypertension (mean 24-h SBP ≥ 130 and/or diastolic BP ≥ 80 mmHg) was 23.2% for ibuprofen, 19.0% for naproxen, and 10.3% for celecoxib…”
How Do NSAIDs Raise Blood Pressure?
A review of the causes of hypertension came up with these mechanisms (Annals of Translational Medicine, Sept, 2017):
“Nonsteroidal anti-inflammatory drugs increase blood pressure by influencing prostaglandin production causing adverse renal effects. Nonsteroidal anti-inflammatory drugs also increase systemic vascular resistance by increased endothelin-1 synthesis and by altered arachidonic metabolism. In 9,411 patients aged 65 years and older, use of nonsteroidal anti-inflammatory drugs increased the risk of starting antihypertensive drug treatment 1.55 times if low daily doses were used, 1.64 times if medium daily doses were used, and 1.82 times if high daily doses were used.”
NSAIDs and Heart Attacks:
The FDA has reported that NSAIDs can have adverse cardiovascular outcomes.
“The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID. The risk my increase with longer use of the NSAID.
“The risk appears greater at higher doses…
“NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease…”
Pain and Blood Pressure:
Dentists have noted that dental checkups and treatment can be stressful for some patients (International Dental Journal, Feb. 1991):
“Local anesthesia and tooth extraction activate the adrenal cortex to produce cortisol. Changes in adrenaline or noradrenaline concentrations have been reported in plasma and urine after drilling and filling or extraction, and anticipation of a dental checkup increases blood pressure. Both diastolic and systolic blood pressure rise still further during restorative treatment without local anaesthesia and during extraction. In a study by the same authors, no significant changes in blood pressure were observed during restorative treatment with local anaesthesia, which suggests that the pain experienced by the patient contributes to the rise in blood pressure.”
I am not at all surprised to learn that “restorative treatment without local anesthesia and during extraction” raised blood pressure. I am so old I can tell you that my first dentist used to drill my teeth with no local anesthesia. He also used a low-speed drill that vibrated my whole mouth. That was not a pleasant experience, but he was a kind and gentle man and I do not have a phobia about dental work.
Will Acetaminophen Raise Blood Pressure?
The makers of Tylenol are advertising that their pain reliever
“Won’t raise blood pressure the way that Advil, Aleve or Motrin sometimes can.”
That sounds reassuring, but you will notice that the commercial does not say acetaminophen (Tylenol) won’t raise blood pressure at all.
The question: does acetaminophen raise blood pressure? is complicated. Researchers have found that both acetaminophen and NSAIDs “independently increase the risk of hypertension in women” (Hypertension, Sept. 2005).
There is this analysis of 80,020 women in the Nurses’ Health Study II (Archives of Internal Medicine, Oct. 28, 2002):
“Conclusions: Use of NSAIDs and use of acetaminophen were significantly associated with increased risk of hypertension, but aspirin use was not. A substantial proportion of hypertension in the United States, and the associated morbidity and mortality, may be due to the use of these medications.”
There is also a similar association in men (Archives of Internal Medicine, Feb. 26, 2007):
“After adjusting for multiple potential confounders, men who used acetaminophen 6 to 7 days per week compared with nonusers had a relative risk for incident hypertension of 1.34.”
“The frequency of nonnarcotic analgesic use is independently associated with a moderate increase in the risk of incident hypertension. Given the widespread use of these medications and the high prevalence of hypertension, these results may have important public health implications.”
British investigators reviewed the available data in the British Journal of Clinical Pharmacology (June 2013). They concluded:
“The overall effect of paracetamol (acetaminophen in the US) on BP [blood pressure] is unclear. Given that paracetamol is often suggested as a safer alternative to non-steroidal anti-inflammatory drugs (NSAIDs), it would seem that further prospective evidence is now needed to address the effect of paracetamol on BP.”
That seems a bit ambiguous. Here is a little more worrisome conclusion from these authors:
“The recent evidence suggests that paracetamol should be used with caution in patients with established CAD [coronary artery disease]. Having performed a systematic review of the literature there appears to be additional clinical trial data supporting the association between paracetamol use and BP elevation in patients with hypertension. Given that there is a plausible biological mechanism for an increase in BP with paracetamol, it may be that we have a misplaced confidence in the cardiovascular safety of paracetamol.”
That same year Scottish researchers concluded that acetaminophen use is not associated with a rise in blood pressure when used by hypertensive patients (Journal of Hypertension, July, 2013).
Here are their conclusions:
“Recent data suggest that self-reported acetaminophen use is associated with increased risk of cardiovascular events and a rise in arterial blood pressure (BP). We investigated the association between acetaminophen use and BP in a large cohort of patients with hypertension using verified prescription data.
“We found no evidence of a sustained rise in blood pressure caused by acetaminophen treatment in a large population of patients with treated hypertension.”
What a Mess!
If you are feeling confused, we would not blame you. A more recent review in the journal Hypertension (July 7, 2022) offers a more cautious overview.
The authors try harder to answer the question: Does Acetaminophen Raise Blood Pressure?
“It seems that acetaminophen does indeed raise blood pressure, affect anticoagulation by warfarin through an effect on vitamin K metabolism, and may increase cardiovascular risk…When an NSAID is prescribed (including acetaminophen) for a patient with hypertension, blood pressure should be monitored, and antihypertensive medication may require adjustment.”
We don’t have a crystal-clear answer to the question: does acetaminophen raise blood pressure in susceptible people? There is a surprising lack of research into this concern. We suspect that occasional use may not pose a problem. Aspirin does not appear to increase blood pressure the way other NSAIDs do.
What Can You Do?
There is one thing that you can do: measure your blood pressure! Do this before taking pain relievers like acetaminophen, ibuprofen, naproxen or any other NSAID. Do it again while taking such meds. We always encourage people to keep a diary. If you see a change in the wrong direction you may have to seek other alternatives or start taking BP meds under a doctor’s supervision.
To help you avoid other things that can contribute to hypertension, you may find our eGuide to Blood Pressure Solutions helpful. This online resource is available in the Health eGuides section.
You may also find our eGuide to Alternatives for Arthritis helpful, since it offers non-NSAID ways to deal with joint pain. If you would prefer a book rather than an electronic eGuide, here is a link to our printed version of this Arthritis guide.
Please share your own experience with blood pressure and pain meds in the comment section below.
