From the Research
Starting aspirin 81 mg daily for a patient with Heart Failure with Reduced Ejection Fraction (HFrEF) and a high coronary artery calcium score is generally not recommended based solely on these factors. Aspirin therapy should be reserved for patients with established atherosclerotic cardiovascular disease (such as prior heart attack, stroke, or documented coronary artery disease) or those with very high cardiovascular risk with additional risk factors 1. While a high coronary calcium score indicates atherosclerotic burden, it alone does not necessarily warrant aspirin therapy, especially considering the bleeding risks associated with aspirin. For patients with HFrEF, guideline-directed medical therapy should focus on medications that improve outcomes in heart failure, including ACE inhibitors or ARBs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors 2, 3. If the patient has a specific indication for aspirin such as recent acute coronary syndrome or percutaneous coronary intervention with stenting, then aspirin would be appropriate. The decision to start aspirin should be individualized based on a comprehensive assessment of the patient's atherosclerotic cardiovascular disease risk, bleeding risk, and other comorbidities, ideally in consultation with both heart failure and preventive cardiology specialists.
Some key points to consider in this decision include:
- The patient's overall cardiovascular risk profile, including the presence of other risk factors such as hypertension, diabetes, and dyslipidemia
- The patient's bleeding risk, including the presence of any bleeding disorders or concomitant use of other anticoagulant or antiplatelet medications
- The potential benefits and risks of aspirin therapy in the context of HFrEF, including the potential for improved cardiovascular outcomes versus the risk of bleeding complications
- The availability of alternative antiplatelet therapies, such as P2Y12 inhibitors, which may have a more favorable risk-benefit profile in certain patients 4.
Ultimately, the decision to start aspirin therapy in a patient with HFrEF and a high coronary artery calcium score should be made on a case-by-case basis, taking into account the individual patient's unique risk profile and medical history.