ON NSIAIDs: ALL antiinflammatories seem to be associated with heart disease

Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis.J Hippisley-Cox, C CouplandBMJ 2005 6;330(7504):1366

This important observational study is the first of probably more to come suggesting that the increased cardiovascular (CV) risk initially attributed to Cox-2 selective agents may indeed be a class effect involving all NSAIDs. This was a very large nested case-controlled study from the UK surveyed 367 primary care practices between 2000 and 2004 to determine the CV risks of patients taking Cox-2 selective agents and other NSAIDs. The risks were determined in patients with and without preexisting coronary heart disease and with and without aspirin usage. Over 9000 initial myocardial infarctions (MI) were observed and compared to over 86,000 age and sex-matched controls. A significantly increased risk of MI was noted with diclofenac, rofecoxib, and ibuprofen and increased trends (but not significant) were noted for naproxen, other NSAIDs, and the other Cox-2 agents. The odds ratios were adjusted for comorbidities, smoking status, statin use, and aspirin use. Of note is a paper at EULAR by G Singh and associates in Vienna (June, 2005) which reported similar findings from a very large California based Medicaid program. They concluded that drug selectivity did not appear to be a factor in increased CV risk in that indomethacin, sulindac, and meloxicam all showed CV risks higher than rofecoxib. These findings suggest that we reconsider the proposed imbalance of prostacyclin and thromboxane associated with the Cox-2 selective agents and again consider the effects of all NSAIDs on renal function with fluid retention and hypertension. Large randomized placebo controlled studies with all traditional NSAIDs and Cox-2 agents will be needed to confirm or refute these observational studies suggesting increased CV risk of all available NSAIDs and Cox-2 selective agents. Arthur L. Weaver MD, MS