The use of non-steroidal anti-inflammatory drugs (NSAID) is associated with a number of gastrointestinal and other adverse effects. Introduction of selective cyclooxygenase-2 (COX-2) inhibitors at the end of the 20th century raised hopes for a substantial reduction in the rate of serious events such as upper gastrointestinal ulcers, bleeding and perforations. In 2004 and 2005, predictions of some pharmacologists were confirmed when the Adenomatous Polyp Prevention on VIOXX trial (APPROVE) and other randomized, double-blind, placebo-controlled trials with COX-2 inhibitors showed an increased rate of thrombotic vascular events, including myocardial infarction, in patients treated with coxibs. So far, only limited long-term data on cardiovascular risk associated with non-selective NSAID have been available; however, some studies have suggested that both selective COX-2 inhibitors and traditional NSAID increase the risk of cardiovascular events. For patients at high cardiovascular risk, contradictory warnings and recommendations have been published recently by the American Heart Association, Food and Drug Administration, and by independent experts. The current paper reviews these recommendations and discusses the therapeutic challenge to minimize the risk of serious adverse events associated with the use of NSAID.