Coronary Artery Calcium for Personalized Allocation of Aspirin in Primary Prevention of Cardiovascular Disease in 2019: The MESA Study (Multi-Ethnic Study of Atherosclerosis)
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Background: Recent American College of Cardiology/American Heart Association Primary Prevention Guidelines recommended considering low-dose aspirin therapy only among adults 40 to 70 years of age who are at higher atherosclerotic cardiovascular disease (ASCVD) risk but not at high risk of bleeding. However, it remains unclear how these patients are best identified. The present study aimed to assess the value of coronary artery calcium (CAC) for guiding aspirin allocation for primary prevention by using 2019 aspirin meta-analysis data on cardiovascular disease relative risk reduction and bleeding risk. Methods: The study included 6470 participants from the MESA Study (Multi-Ethnic Study of Atherosclerosis). ASCVD risk was estimated using the pooled cohort equations, and 3 strata were defined: <5%, 5% to 20%, and >20%. All participants underwent CAC scoring at baseline, and CAC scores were stratified as =0, 1 to 99, ≥100, and ≥400. A 12% relative risk reduction in cardiovascular disease events was used for the 5-year number needed to treat (NNT 5 ) calculations, and a 42% relative risk increase in major bleeding events was used for the 5-year number needed to harm (NNH 5 ) estimations. Results: Only 5% of MESA participants would qualify for aspirin consideration for primary prevention according to the American College of Cardiology/American Heart Association guidelines and using >20% estimated ASCVD risk to define higher risk. Benefit/harm calculations were restricted to aspirin-naive participants <70 years of age not at high risk of bleeding (n=3540). The overall NNT 5 with aspirin to prevent 1 cardiovascular disease event was 476 and the NNH 5 was 355. The NNT 5 was also greater than or similar to the NNH 5 among estimated ASCVD risk strata. Conversely, CAC≥100 and CAC≥400 identified subgroups in which NNT 5 was lower than NNH 5 . This was true both overall (for CAC≥100, NNT 5 =140 versus NNH 5 =518) and within ASCVD risk strata. Also, CAC=0 identified subgroups in which the NNT 5 was much higher than the NNH 5 (overall, NNT 5 =1190 versus NNH 5 =567). Conclusions: CAC may be superior to the pooled cohort equations to inform the allocation of aspirin in primary prevention. Implementation of current 2019 American College of Cardiology/American Heart Association guideline recommendations together with the use of CAC for further risk assessment may result in a more personalized, safer allocation of aspirin in primary prevention. Confirmation of these findings in experimental settings is needed.
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Large, observational, prospective data suggest coronary artery calcium as a non-invasive biomarker to identify asymptomatic patients at the highest risk of ASCVD or revascularization, with or without diabetes, who may largely benefit from acetylsalicylic acid.
“Large, observational, prospective data suggest CAC as a non-invasive biomarker to identify asymptomatic patients at the highest risk of ASCVD or revascularization, with or without diabetes, who may largely benefit from ASA.”
From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [295]
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- Authors
- Cainzos-Achirica, M., Miedema, M. D., McEvoy, J. W., Al Rifai, M., Greenland, P., Dardari, Z., Budoff, M., Blumenthal, R. S., Yeboah, J., Duprez, D. A., Mortensen, M. B., Dzaye, O., Hong, J., Nasir, K., & Blaha, M. J.
- Affiliations
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.).
- Minneapolis Heart Institute Foundation (US)
- Johns Hopkins University (US)
- Baylor College of Medicine, Houston, TX (M.A.R.).
- Northwestern University (US)
- University of California, Los Angeles (US)
- Atrium Health Wake Forest Baptist (US)
- University of Minnesota (US)
- Aarhus University Hospital (DK)
- ORCID
- Venue
- Circulation
- Published
- 2020-05-12
- Volume
- 141
- Issue
- 19
- Pages
- 1541-1553
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- PMC
- PMC7217722
- OpenAlex
- W3014628403
- Cited by
- 201
- References
- 32
- Citations by year
- 2026: 25 · 2025: 33 · 2024: 32 · 2023: 32 · 2022: 33 · 2021: 32 · 2020: 14
- FWCI
- 17.16
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institutes of Health (n01hc95164-17-0-1, UL1TR001420, n01hc95165-34-0-1, n01hc95161-24-0-1, n01hc095169-003, n01hc95166-21-0-1, n01hc95162-31-0-1, n01hc95168-27-0-1, n01hc95160-18-0-1, n01hc095167-000, UL1TR001079, n01hc95159-40-0-1, UL1TR003098, UL1TR000040, UL1TR001881)
- National Heart, Lung, and Blood Institute (N01 HC-95159, N01-HC095169, N01-HC-095165, UL1-TR-, N01-HC-095159, N01 HC095168, N01-HC-095162, N01-HC-095161, HHSN268201500003C, HHSN26820150 0003I, N01 HC095167, N01-HC-095160, N01 HC095166, N01 HC095164, UL1-TR-000040, UL1-TR-001079, UL1-TR-001420, N01 HC95169)
- National Center for Advancing Translational Sciences (UL1-TR-000040, UL1-TR-001079, UL1-TR, N01-HC-95159, HHSN268201500003I, N01-HC-95169, UL1-TR-000040, UL1-TR-001079, UL1-TR-001420)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Keywords
- coronary artery calcium, aspirin, primary prevention, cardiovascular disease, atherosclerotic cardiovascular disease risk, bleeding risk, number needed to treat, number needed to harm, risk stratification, Pooled Cohort Equations, benefit-harm assessment, statin therapy
- MeSH terms
- Clinical Decision-Making, Computed Tomography Angiography, Heart Disease Risk Factors, Aged, Aged, 80 and over, Aspirin, Coronary Artery Disease, Female, Hemorrhage, Humans, Male, Middle Aged, Myocardial Infarction, Platelet Aggregation Inhibitors, Primary Prevention, Prospective Studies, Time Factors, United States, Incidence, Treatment Outcome, Coronary Angiography, Risk Assessment, Stroke, Vascular Calcification
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