Does a 56-year-old male patient with a Coronary Artery Calcification (CAC) score of 156.6 require aspirin (acetylsalicylic acid) therapy?

From the Guidelines

Aspirin therapy is not automatically indicated for a 56-year-old male patient with a coronary artery calcium (CAC) score of 156.6, and the decision to start aspirin should be individualized based on overall cardiovascular risk assessment rather than the CAC score alone. For this patient, a comprehensive cardiovascular risk assessment should be performed, including evaluation of additional risk factors such as hypertension, diabetes, smoking status, family history, and cholesterol levels. According to the 2024 ESC guidelines for the management of chronic coronary syndromes 1, aspirin 75–100 mg daily may be considered in patients without a history of MI or revascularization, but with definitive evidence of CAD on imaging, which is a IIb recommendation with a Level of Evidence C. However, the most recent and highest quality study, the 2024 ESC guidelines, also states that in patients without prior MI or revascularization but with evidence of significant obstructive CAD, aspirin 75–100 mg daily is recommended lifelong, which is a Class I recommendation with a Level of Evidence B.

If the patient's 10-year atherosclerotic cardiovascular disease risk is elevated (typically >10%), and bleeding risk is low, low-dose aspirin (81 mg daily) might be considered. However, the net benefit of aspirin must be weighed against potential bleeding risks. Primary prevention with aspirin has become more selective in recent years as research has shown that the bleeding risks may outweigh cardiovascular benefits in many patients without established cardiovascular disease. The patient should discuss this decision with their healthcare provider who can evaluate their complete risk profile and make a personalized recommendation.

Some key points to consider in this decision include:

• The patient's overall cardiovascular risk profile, including factors such as hypertension, diabetes, and cholesterol levels
• The presence of any contraindications to aspirin therapy, such as bleeding disorders or active gastrointestinal bleeding
• The potential benefits of aspirin therapy in reducing the risk of cardiovascular events, such as myocardial infarction or stroke
• The potential risks of aspirin therapy, including bleeding complications and gastrointestinal side effects.

It is also important to note that the 2007 ACC/AHA guidelines for the management of patients with chronic stable angina 1 and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1 provide additional guidance on the use of aspirin in patients with coronary artery disease, but the 2024 ESC guidelines 1 are the most recent and highest quality study.

In terms of specific recommendations, the 2024 ESC guidelines 1 suggest that aspirin 75–100 mg daily may be considered in patients without a history of MI or revascularization, but with definitive evidence of CAD on imaging. However, the decision to start aspirin should be individualized based on the patient's overall cardiovascular risk profile and the potential benefits and risks of therapy.

Ultimately, the decision to start aspirin therapy in a patient with a CAC score of 156.6 should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history. The patient should discuss this decision with their healthcare provider, who can evaluate their complete risk profile and make a personalized recommendation.

From the Research

Aspirin Therapy for a 56-Year-Old Male Patient with a CAC Score of 156.6

• The patient's Coronary Artery Calcification (CAC) score of 156.6 indicates a significant presence of coronary atherosclerosis, as CAC is a highly specific feature of this condition 2.
• According to the study published in the Journal of the American College of Cardiology, CAC scoring is a widely available, consistent, and reproducible means of assessing risk for major cardiovascular outcomes, especially useful in asymptomatic people for planning primary prevention interventions such as statins and aspirin 2.
• However, the role of aspirin for primary prevention of cardiovascular diseases remains controversial, particularly in the context of contemporary aggressive preventive strategies 3.
• A meta-analysis published in The American Journal of Medicine found that aspirin use decreased myocardial infarction risk by 16% compared with placebo, but also significantly increased the occurrence of major bleeding and hemorrhagic stroke 3.
• Another study published in The American Journal of Cardiology found that in patients with severe hypercholesterolemia, CAC scoring may be used to clarify atherosclerotic cardiovascular disease (ASCVD) risk, and that a higher CAC category was associated with increased statin use after CAC scoring 4.
• A systematic review published in The American Journal of Cardiology found that in the absence of a significant bleeding risk, increased ASCVD risk and CAC score correlate with increased benefit from aspirin, and that patients with CAC ≥100 may experience a net benefit from aspirin therapy 5.
• Considering the patient's CAC score of 156.6, which is greater than 100, and assuming the absence of a significant bleeding risk, aspirin therapy may be beneficial for primary prevention of cardiovascular events 5.

Key Considerations

• The decision to initiate aspirin therapy should be based on a comprehensive assessment of the patient's individual risk factors, including bleeding risk, ASCVD risk, and CAC score 3, 5.
• The patient's age, male gender, and other comorbidities, such as diabetes, hypertension, and smoking status, should also be taken into account when evaluating the potential benefits and risks of aspirin therapy 2, 4.