Use of Coronary Artery Calcification Score for Personalization of Aspirin Usage

It was shown many years ago that the use of aspirin, which inhibits blood clotting, can be useful in treating patients with heart disease as the primary ‘event’ is the rupture of an atherosclerotic plaque resulting in potentially clotting off the blood flow to a vital heart [coronary] artery.  This is called ‘secondary prevention’ – that is once we know you have had a cardiac event, such as a heart attack, we want to prevent another one occurring; this is established clinical practice.

However, what if you have never had a cardiac ‘event’ but may or may not be ‘at risk’ for this to happen in the future?  Treating patients in this category is called ‘primary prevention’ – that is we want to prevent the FIRST heart attack.  Traditionally most doctors have used a compilation of ‘risk factors’ such as smoking, hypertension, high cholesterol, diabetes and the like to potentially define your ‘risk’.  Such ‘pooled cohort’ calculations are commonly employed by your doctors and are used to determine how aggressively we should consider treating your cholesterol or blood pressure.  But what about the use of standard or low dose aspirin for ‘primary prevention’?

Of late there has been a major controversy in that the heart associations have determined that use of aspirin may be helpful for those at ‘risk’ for heart disease, but this needs to be mitigated against the small but real risk of bleeding [like damage to the stomach lining and blood ‘thinning’] using aspirin.

Again, the associations have gone back to the risk factors or risk equations to provide the answer and have indicated that only those at highest primary risk should be considered for aspirin therapy.  The problem is that atherosclerosis or hardening of the arteries is a slow developing but continuous process that progresses silently until an ‘event’.

For nearly 20 years, Princeton Longevity Center has used the ‘Heart Scan’ or coronary artery calcium {CAC} scan of the heart to define your personal cardiac ‘risk’, since it looks at your actual situation and not via ‘equations’ that are applied to the masses; in other words, the equations work when applied to a collection of 1,000 patients similar to you, but may not apply to you personally.

In general, if the CAC ‘score’ is >100, indicating moderate atherosclerotic plaque development, the PLC has strongly suggested the use of aspirin for ‘primary prevention’ – this has been based on various publications over the years.

Most recently a publication in the American Heart Association Circulation Journal investigators has shown in the MESA Study [Multi-ethnic Study of Atherosclerosis] that only 5% of the participants in the CAC scoring protocol [out of 6470 ‘primary prevention’ patients] would have qualified for low dose aspirin therapy using the ‘risk’ equations.  However, each participant had CAC scoring and long term follow up for subsequent cardiac ‘events.  They confirmed that a CAC score >100 was superior in defining ‘high risk’ patients.  The authors concluded: “…. Implementation of current 2019 American College of Cardiology/American Heart Association guideline recommendations together with the use of CAC [scoring] for further risk assessment may result in a more personalized, safer allocation of aspirin in primary prevention.”