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Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the
Michael D Miedema1, Daniel A Duprez2, Jeffrey R Misialek2
1From the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN (M.D.M.); Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, MA (M.D.M.); Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.); Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (J.R.M., A.R.F.); Ciccarone Preventive Cardiology Center, Johns Hopkins School of Medicine, Baltimore, MD (M.J.B., K.N., M.G.S.); Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL (K.N.); Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami (K.N.); Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL (K.N.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (R.B.); Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA (M.J.B.); and Department of Preventive Medicine (P.G.) and Department of Medicine (P.G.), Northwestern University Feinberg School of Medicine, Chicago, IL. mdm307@mail.harvard.edu.
Insights
Coronary artery calcium (CAC) scoring can guide aspirin use for primary prevention of coronary heart disease (CHD). Individuals with CAC score of 100 or higher may benefit from aspirin, while those with zero CAC may experience harm.
Area of Science:
- Cardiology
- Preventive Medicine
- Medical Imaging
Background:
- Aspirin is recommended for primary prevention of coronary heart disease (CHD) only in high-risk individuals.
- Most CHD events occur in individuals at low to intermediate risk, who are not typically candidates for aspirin therapy.
- Current guidelines do not fully address aspirin use for primary prevention in lower-risk populations.
Purpose of the Study:
- To evaluate the utility of coronary artery calcium (CAC) scoring in guiding aspirin use for primary prevention of CHD.
- To compare the estimated number needed to treat (NNT) with aspirin against the number needed to harm (NNH) for major bleeding across different risk strata defined by CAC scores.
- To assess the net clinical benefit of aspirin based on CAC status and traditional risk factors.
Main Methods:
- Analysis of 4229 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort, free of diabetes and not on aspirin at baseline.
- Calculation of 5-year NNT for aspirin based on an 18% relative CHD reduction applied to observed event rates.
- Calculation of 5-year NNH for major bleeding using data from an aspirin meta-analysis.
- Stratification of results by 10-year CHD Framingham Risk Score (FRS) and CAC scores (≥100 vs. zero).
Main Results:
- Individuals with CAC score ≥100 demonstrated a net benefit from aspirin, with lower NNT compared to NNH, irrespective of FRS.
- For individuals with CAC ≥100 and <10% FRS, the estimated 5-year NNT was 173 (NNH 442).
- For individuals with zero CAC, the estimated 5-year NNT was substantially higher (2036 for <10% FRS, 808 for ≥10% FRS), indicating net harm from aspirin.
- Sex-specific and age-stratified analyses yielded similar risk-benefit estimations.
Conclusions:
- CAC scoring can effectively identify individuals who may benefit from aspirin for primary CHD prevention.
- Participants with CAC ≥100 have a favorable risk-benefit profile for aspirin use.
- Participants with zero CAC are estimated to experience net harm from aspirin therapy for primary prevention.
Background:
Aspirin for the primary prevention of coronary heart disease (CHD) is only recommended for individuals at high risk for CHD although the majority of CHD events occur in individuals who are at low to intermediate risk.
Methods And Results:
To estimate the potential of coronary artery calcium (CAC) scoring to guide aspirin use for primary prevention of CHD, we studied 4229 participants from the Multi-Ethnic Study of Atherosclerosis who were not on aspirin at baseline and were free of diabetes mellitus. Using data from median 7.6-year follow-up, 5-year number-needed-to-treat estimations were calculated by applying an 18% relative CHD reduction to the observed event rates. This was contrasted to 5-year number-needed-to-harm estimations based on the risk of major bleeding reported in an aspirin meta-analysis. Results were stratified by a 10% 10-year CHD Framingham Risk Score (FRS). Individuals with CAC≥100 had an estimated net benefit with aspirin regardless of their traditional risk status (estimated 5-year number needed to treat of 173 for individuals <10% FRS and 92 for individuals ≥10% FRS, estimated 5-year number needed to harm of 442 for a major bleed). Conversely, individuals with zero CAC had unfavorable estimations (estimated 5-year number needed to treat of 2036 for individuals <10% FRS and 808 for individuals ≥10% FRS, estimated 5-year number needed to harm of 442 for a major bleed). Sex-specific and age-stratified analyses showed similar results.
Conclusions:
For the primary prevention of CHD, Multi-Ethnic Study of Atherosclerosis participants with CAC≥100 had favorable risk/benefit estimations for aspirin use while participants with zero CAC were estimated to receive net harm from aspirin.