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.
REFERENCES
- 1.Li YH, Yeh HI, Tsai CT, et al. 2012 Guidelines of the Taiwan Society of Cardiology (TSOC) for the management of ST-segment elevation myocardial infarction. Acta Cardiol Sin. 2012;28:63–89. [Google Scholar]
- 2.Kearney PM, Baigent C, Godwin J, et al. Do selective cyclooxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomized trials. BMJ. 2006;332:1302–1308. doi: 10.1136/bmj.332.7553.1302. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. 2008;117:296–329. doi: 10.1161/CIRCULATIONAHA.107.188209. [DOI] [PubMed] [Google Scholar]
- 4.O’Connor RE, Brady W, Brooks SC, et al. Part 10: Acute Coronary Syndrome: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S787–S817. doi: 10.1161/CIRCULATIONAHA.110.971028. [DOI] [PubMed] [Google Scholar]