Cyclo-oxygenase-2 (COX 2) inhibitors should be used only as the last choice after other types of non-steroidal anti-inflammatory drugs (NSAIDs) to relieve chronic pain in people with heart disease or at high risk of it, the American Heart Association has recommended. Its statement, which will be published this month in Circulation (http://circ.ahajournals.org), was designed to end any remaining confusion about the cardiovascular risk of these agents.

The association has recommended a stepped approach to treatment. The first step should be non-pharmacological approaches, such as physical therapy and weight loss, for patients with known cardiovascular disease or with risk factors for ischaemic heart disease. Drug treatment should start with agents with the lowest …