The Impact of NSAID Selection on Gastrointestinal Injury and Risk for Cardiovascular Events: Identifying and Treating Patients at Risk

Recall appropriate therapeutic recommendations with respect to cardiovascular and gastrointestinal patient risk factors. Educational Objectives strated a reduced risk of gastrointestinal mucosal injury. However, there appears to be a delicate balance between the ability to protect the gastric mucosa and the effect on thrombotic events. Although selective COX-2 inhibitors appear to protect the gastric mucosa as a result of their selectivity, this same mechanism may cause an increased tendency toward thrombosis; several analyses suggest that these agents, compared with traditional NSAIDs, may increase a patient’s risk for cardiovascular events.5,6 Gastrointestinal mucosal injury and complications associated with the use of COX-1/COX-2 NSAIDs, along with the risk of cardiovascular effects associated with selective COX-2 NSAIDs, have left clinicians in a quandary as to the ideal analgesic-cardioprotective regimen to use. This dilemma has been further complicated by recent studies demonstrating that naproxen (Naprosyn®, Roche) is more cardioprotective than other NSAIDs.7–9 This article reviews the pathophysiology of the inflammatory response and the pharmacological mechanisms of NSAID activity. Criteria that identify patients at risk for gastrointestinal mucosal injury or cardiovascular events are also presented. In a separate article in this issue, Drs. Fendrick and Garabedian-Ruffalo present a clinician’s guide to selecting NSAID therapy and, if applicable, antisecretory-gastroprotective therapy, as determined by the patient’s risk for gastrointestinal injury and his or her concurrent use of aspirin.10