Coping with heart disease and arthritis together

A lifelong exerciser, Steve cycled, lifted weights, and played pickup basketball into his late 60s, when he had a partial left knee replacement to treat his osteoarthritis. Within a few months, he was back at the gym riding a stationary bike and using the weight machines three to four times a week. He downs some ibuprofen if his knees or other joints start to ache, and he takes two daily blood pressure drugs.

His 73-year-old neighbor Marjorie, who survived a heart attack nearly a year ago, has osteoarthritis in her hips. Her doctor has been encouraging her to exercise, but she finds walking uncomfortable. Her medications include low-dose aspirin and clopidogrel to prevent blood clots, rosuvastatin to control her cholesterol, and metformin to manage her diabetes.

Like Steve and Marjorie, many people with cardiovascular conditions also deal with painful joint damage from osteoarthritis. Regular exercise benefits both conditions, but joint pain can make certain types of exercise difficult. What's more, some popular pain relievers for arthritis interact with common cardiovascular drugs — with potentially worrisome repercussions. Here's what you need to know if you're coping with both of these health problems together.

Exercise advice

Steve's current exercise regimen makes good sense and will benefit both his heart and his joints. "Using a recumbent or stationary bike is much easier on your joints than walking," says Jim Zachazewski, a physical therapist and athletic trainer with Mass General Brigham Sports Medicine. When you walk, every step puts a load on your joints equal to twice your body weight or more, he explains. Other low-impact exercise machines like ellipticals or stair steppers are also good choices.

However, many people like walking because it's convenient and affordable. Note that walking on a concrete sidewalk puts more pressure on your knee and hip joints than walking on a softer surface such as grass, dirt, or wood chips, says Zachazewski. "Another good option is to walk around the track at a local high school. The rubberized surface is shock-absorbing and even more forgiving to joints," he says. Some exercise facilities also have indoor walking and running tracks. Be sure to wear well-fitting, cushioned athletic shoes when you exercise, he adds.

For people like Marjorie, aquatic exercise can be a great option. Because you're buoyant, moving through water takes the stress off your joints, while the added resistance provides a challenging muscle workout. Don't like to swim? Try walking or jogging in water that's at least waist-deep. "You can also wear a flotation belt in deep water and bicycle your legs," says Zachazewski. If you have shoulder arthritis, stand in neck-deep water and hold an empty, capped soda bottle in your outstretched hand. Moving the bottle up and down and from side to side under the water can be an effective upper-body exercise, even for people who've had shoulder surgery, he says. For more information, see "What makes water workouts so worthwhile?" in the August 2023 Heart Letter.

If you're having any issues creating an exercise routine, ask your doctor for a referral to a physical therapist. He or she can help you design an activity program you can tolerate and, if needed, recommend assistive devices such as braces, canes, or walkers that can help you be more mobile.

Medication management

To treat pain and inflammation, many people with osteoarthritis rely on nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and the prescription drug celecoxib (Celexa). "But NSAIDs cause the kidneys to hold on to salt and water, which can also raise blood pressure. And studies show a link between these drugs and a higher risk of heart attack," says Dr. Robert H. Shmerling, senior faculty editor for Harvard Health Publishing and former clinical chief of rheumatology at Beth Israel Deaconess Medical Center.

For someone like Steve whose blood pressure is well controlled, taking ibuprofen or another NSAID a few times a week is unlikely to cause a problem, especially if it makes regular exercise and activity more tolerable. However, he should check his blood pressure periodically to make sure it's not rising.

But Marjorie would be better off taking acetaminophen (Tylenol) for pain instead of ibuprofen, Dr. Shmerling cautions. That's because she's already taking low-dose aspirin to prevent a second heart attack. Ibuprofen can interfere with aspirin's anti-clotting activity, possibly negating its beneficial effect for the heart. However, you can avoid this possible problem by waiting at least 30 minutes after taking the low-dose aspirin to take ibuprofen or naproxen (or alternatively, taking either NSAID at least eight hours before the aspirin).

NSAIDs also increase the risk of bleeding, which ranges from minor problems (such as noticeable bruising) to more serious complications, such as bleeding in the gastrointestinal tract or, in rare cases, the brain. This risk is even greater for people on clot-preventing drugs such as apixaban (Eliquis) and rivaroxaban (Xarelto), which are prescribed to people with atrial fibrillation and other cardio­vascular problems.

If oral NSAIDs irritate your stomach, you can try a topical version instead. Diclofenac is an NSAID that's available without a prescription as a topical gel (such as Aspercreme Arthritis Pain Relief Gel and Voltaren Arthritis Pain Gel). It works best for arthritis in smaller joints and joints near the surface of the skin, such as in the hands, knees, ankles, and feet. It may be less effective for deeper joints, such as the hip and shoulder.

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