Do Not Use Cycloxigenase-2 Inhibitors in STEMI

To the Editor: It is quite encouraging to read the TSOC Guideline article “2012 Guidelines of the Taiwan Society of Cardiology for the Management of ST-Segment Elevation Myocardial Infarction” by Li et al.1 Though I wholeheartedly agree with and appreciate this guideline, I find it necessary to take issue with a comment about nonsteroidal anti-inflammatory drugs (NSAIDs) because the reader may be confused from the statement “NSAIDs, except aspirin, and cycloxygenase-2 (COX-2) inhibitors, should not be used at the acute stage of STEMI”. NSAIDs contain diverse groups of drugs with analgesic, antipyretic, and anti-inflammatory effects. Most NSAIDs function as a nonselective inhibitor of the enzyme cyclooxygenase (COX) to block the formation of prostaglandins and thromboxane, enabling the body to ease off its inflammatory reaction. Gastrointestinal irritation is one of the main adverse drug reactions (ADRs) of NSAIDs. The discovery of selective COX-2 inhibitors brought attention to the NSAIDs with decreased gastrointestinal ADRs. However, selective COX-2 inhibitors were later found to increase the risks of re-infarction, stroke and vascular death.2 Immediate discontinuation of COX-2 inhibitors and other NSAIDs except for aspirin at the time of STEMI was thereafter recommended.3 The latest emergency cardiac care guideline re-emphasized that NSAIDs other than aspirin, both nonselective and COX-2 selective, should not be administered during hospitalization for STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use (Class III, LOE C).4 For genetic and lifestyle differences, it should be the era to have our own guidelines.