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Older patients are the most likely to use non-steroidal anti-inflammatory drugs (NSAIDs) and are at the highest risk of developing incident heart failure. In their paper published in this issue of Heart, von den Hondel et al1 present imaging data from the Rotterdam Study highlighting the phenotypic manifestation of NSAID use on the heart, with putative mechanistic implications (see page 540). The study elegantly demonstrates an association between current NSAID use and adverse effects on echocardiographic parameters in the short term in a large, older, population-based cohort with a high participation rate. The burden of NSAID use in the study and control groups also appears to be well documented. The absence of a dose–response relationship, at least for echocardiographic parameters of left ventricular size, is somewhat unexpected, but could have been confounded because only one study was performed. The authors correctly acknowledge the limitations of the study, the most pertinent being the performance of a single imaging study. It would …