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Invited Commentary
October 28, 2020

Coronary Artery Calcium for Personalized Risk Management—A Second Chance for Aspirin in Primary Prevention?

Author Affiliations
  • 1Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
  • 2Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
  • 3Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
JAMA Cardiol. Published online October 28, 2020. doi:10.1001/jamacardio.2020.4961

Over the last 2 years, use of low-dose aspirin for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) has become one of the most debated topics in cardiology.1,2 Initial trials conducted between the 1980s and early 2000s suggested a significant benefit in a primary prevention population at high risk. However, with expanded use of statins and declining ASCVD rates in Western countries in the last 2 decades, the benefit of prophylactic aspirin became progressively less certain among individuals without established ASCVD. Three trials1,2 published in 2018 found no benefit or modest benefit with aspirin and raised concerns about the potential for net harm in populations at increased bleeding risk. Still, given some trial and updated meta-analytic evidence of modest reductions in nonfatal ASCVD events, the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) primary prevention guideline acknowledged that aspirin could have a role in helping candidates who are adequately selected: individuals younger than 70 years at low risk of bleeding and highest risk of ASCVD events (class IIb).3

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