SOURCE: Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med 2016;375:2519-2529.

Ever since the publication of the VIGOR trial, in which it was noted that cardiovascular (CV) events were four times more frequent in patients receiving rofecoxib (subsequently withdrawn from the market) than naproxen, warnings about the risk of CV events attributable to nonsteroidal anti-inflammatory drugs (NSAIDs) have become progressively more strident. For instance, the most recent American College of Cardiology/American Heart Association guidelines on acute coronary syndromes place NSAIDs at the bottom of the list of choices to treat musculoskeletal pain, preferring instead even opioid agents such as tramadol.

How does the CV safety profile of various NSAIDs stack up? To address that question, the administrators of the PRECISION trial randomized a large group of arthritis patients (n = 24,081) who were high risk for CV events to naproxen, ibuprofen, or celecoxib. The population was followed for approximately three years.

Although celecoxib produced fewer adverse gastrointestinal and renal events, there was no statistically significant difference among the three agents for CV events. No safe harbor among the NSAIDs has yet been confirmed in a large randomized trial, and the previous supposition that naproxen was a safer NSAID (from the CV perspective) appears to be incorrect.