From the Guidelines
Aspirin therapy is recommended for patients with an elevated Coronary Artery (CA) Vulnerability (CAV) score, particularly those with evidence of significant obstructive CAD, as it has been shown to reduce the risk of non-fatal MI, non-fatal ischemic stroke, or death from vascular causes 1. The decision to initiate aspirin therapy should be individualized based on the patient's overall cardiovascular risk profile, including their CAV score, bleeding risk, age, and other medications.
- The 2024 ESC guidelines for the management of chronic coronary syndromes recommend aspirin 75–100 mg daily for patients with a prior MI or revascularization, as well as for those without a history of MI or revascularization but with evidence of significant obstructive CAD 1.
- A study published in the European Heart Journal found that low-dose aspirin (75–100 mg once daily) significantly reduced the combined risk of non-fatal MI, non-fatal ischemic stroke, or death from vascular causes in patients with chronic coronary syndrome 1.
- The benefits of aspirin therapy must be balanced against the increased bleeding risk, and patients should discuss their individual risk profile with their healthcare provider before starting aspirin.
- Daily aspirin doses of 75–100 mg seem to be as effective as higher doses for long-term treatments, and there is no evidence of different aspirin effects in women and men 1. Key considerations for aspirin therapy in patients with an elevated CAV score include:
- The presence of significant obstructive CAD
- The patient's bleeding risk
- The patient's age and other medications
- The potential benefits of aspirin therapy in reducing the risk of non-fatal MI, non-fatal ischemic stroke, or death from vascular causes.
From the Research
Patient Eligibility for Aspirin Therapy
To determine if a patient with an elevated Coronary Artery (CA) Vulnerability (CAV) score requires aspirin therapy, several factors must be considered, including the patient's CAC score, ASCVD risk, and bleeding risk.
- A patient with a CAC score of >400 is considered to be at very-high 10-year risk for an atherosclerotic event and may benefit from aspirin therapy for a maximum of 2 years 2.
- For patients with a CAC score ≥100, aspirin confers a net benefit, whereas patients with a high bleeding risk would experience a net harm, irrespective of ASCVD risk or CAC 3.
- The American Heart Association recommends that aspirin only be prescribed for "high-risk" individuals, and a CAC score can be used as the basis for determining "high risk" 2.
CAC Score Interpretation
The interpretation of CAC scores is crucial in determining the risk of cardiovascular events and the potential benefit of aspirin therapy.
- A CAC score of 0 is the strongest negative predictive factor for cardiovascular disease (CVD), and a 0 score can successfully de-risk a patient 4.
- Higher CAC scores correlate with worse cardiovascular prognostic outcomes, and a CAC score >400 places an individual at very-high 10-year risk for an atherosclerotic event 2.
- CAC scores can be categorized into different risk groups, including low risk (CAC=1-100), intermediate risk (CAC=101-400), and high risk (CAC >400) 5.
Aspirin Therapy Recommendations
Based on the available evidence, the following recommendations can be made for aspirin therapy in patients with elevated CAV scores:
- Patients with moderately-high or high risk based on CAC score are recommended to receive preventative medical therapy such as aspirin and statins 5.
- Aspirin and statins are generally not recommended in patients with CAC <100 5.
- In patients with a CAC score ≥100, aspirin may confer a net benefit, but the decision to start therapy should be individualized based on the patient's ASCVD risk and bleeding risk 3, 6.