Except aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk for heart attack and stroke, according to accumulated research evidence.

"Recent studies indicate that the cells lining the blood vessels have more of the COX-2 enzyme than initially thought. So it's possible that inhibiting the COX-2 pathway can make a person's blood more likely to clot.

There is also an increase in sodium and water retention, which in turn could worsen heart failure and produce high blood pressure. The more you inhibit COX-1, the greater the increase in GI risk; the more you inhibit COX-2 the greater the cardiovascular risk."

It is in this context that the American Heart Association is urging doctors (in a statement published in Circulation) to change their way of prescribing pain relievers for chronic pain in patients with (or at risk for) heart disease.

According to Elliott M. Antman, M.D., FAHA, lead author of the American Heart Association scientific statement and Professor of Medicine at Harvard Medical School and Brigham and Women's Hospital:

"We believe that some physicians have been prescribing the new COX-2 inhibitors as the first line of treatment. We are turning that around and saying that, for chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs should be the last line of treatment.

We advise physicians to start with non-pharmacologic treatments such as physical therapy and exercise, weight loss to reduce stress on joints, and heat or cold therapy. If the non-pharmacologic approach does not provide enough pain relief or control of symptoms, we recommend a stepped-care approach when it comes to prescribing drugs."

Read the full report.