Aspirin Use in Patients with High Calcium Scores
Here are 2 great questions from one of our cardiologists and my responses:
Hi Paul, — I’ve been get a bunch of referrals for high coronary calcium scores greater than 400 and even 1000. These are “asymptomatic” patients. I have 2 questions:
1. What is your feeling about baby aspirin in these patients…..given the not so recent positive data on aspirin for primary prevention….is this still primary prevention w/these high scores?
I am not sure that they meet the definition of true secondary prevention, but I still pretty positive on aspirin for people with high CVD risk, and CAC really increases the risk. Why am I still positive on ASA? The early studies of ASA showed that it reduced acute MI. These studies were before widespread troponin measurements (Tn). Tn detects all sorts of MIs and not just those due to plaque rupture and thrombosis, where ASA probably is most helpful. Also, the results of the 3 recent aspirin studies are not as tough on ASA as the NY Times would suggest. In ARRIVE, CVD events were 4.3 for ASA and 4.5 for placebo, but time to first MI was delayed 47% with ASA. Bleeding increased. Events in ARRIVE were similar but it was a low risk group. In ACCEND, a study of diabetics, CVD events were 8.%% for ASA and 9.6% for placebo so a 1.1% reduction, but bleeds increased 0.9%. That is why the study was considered so negative, more bleeding, ie balanced risk vs benefit, but I would prefer a bleed, if not exsanguination, over an MI. The problem study is ASPREE, a study of the elderly, where ASA increased death from any cause, primarily cancer. I don’t understand why more cancer. So, I tend to use low dose ASA, 81 mg, in folks with high CVD risk, such as those with high CAC scores, as long as there is not obvious bleeding risk or they are old…(the definition of which is now over age 72, but will change next year. J ) I am also a fan of ASA when the lipoprotein a is high. There is a study, not sure which study, but maybe the Nurses’ Health Study, that showed that ASA was effective in reducing events in those with elevated Lpa, which is a thrombotic risk factor. So, take home messages: Explain the issues to the patient. If high risk and young, consider ASA. Consider ASA strongly in high CAC scores and those with increased lpa or high risk in general. These issues are discussed in a point/counterpoint in the NEJM May 16, 2019 issue. Two experts who disagree on the issue present their thoughts, both are convincing.
2. How do you approach these patients in terms of stress testing. Do you stress? And if so with imaging (stress echo/nuclear)? I’ve looked into this and the guidelines and data aren’t so clear. My practice has been to stress to simply exclude a high risk stress indicative of high ischemic burden. Also we will at least have a baseline to compare in future.
I do a regular stress test. I want to know if they have symptomatic ischemia. If they can get to a high heart rate and don’t have symptoms, I treat the dickens out of their risk factors, but otherwise leave them alone. I am sure you are aware of studies we have helped in, showing that tons of middle aged athletes have tons of calcium in their arteries. Our relatively recent study on this is in Circulation (2017;136:138–148). None of us know what to do, but I try to avoid intervening unless they have symptoms. I actually don’t want to turn asymptomatic CAC disease into stent disease.
Now these are the opinions of an elderly, short, balding cardiologists, so take them for what they are worth.
Please note I have changed the blog and twitter to “@pauldthompsonmd” for simplicity.
Paul D. Thompson, MD
Chief of Cardiology — Emeritus, Hartford Hospital
Professor of Medicine, University of Connecticut
Telephone: 860–972–1793
Blog — https://medium.com/@pauldthompsonmd
Twitter — @pauldthompsonmd
