Nonsteroidal anti-inflammatory drugs and cardiovascular risk - a matter of indication

The term non-steroidal anti-inflammatory drugs (NSAIDs) covers a heterogeneous group of compounds that possess analgesic, antipyretic and anti-inflammatory properties. NSAIDs are recommended as first-line therapy in patients with ankylosing spondylitis (AS) and are also frequently used in rheumatoid arthritis (RA). However, adverse reactions are relatively common, including an increased risk for cardiovascular events which has remained a concern for both, patients and physicians, and the United States Food and Drug Administration (FDA) has recently expressed a straight forward warning in this regard. Recent data on the use of NSAIDs in inflammatory diseases are now challenging this hypothesis. In two large independent studies, it was not the high but the low intake of NSAIDs that was associated with mortality in AS patients. Analogous data exist for RA. This observation is obviously not consistent with a general increase of cardiovascular mortality due to NSAIDs. Here we discuss the important impact of indication (inflammatory vs. non-inflammatory diseases) on the cardiovascular effects of NSAIDs, including traditional NSAIDs (t-NSAIDS) and coxibs.