Doshi Apoorva, Gandhi Haresh, Patel Kunal N, Majmundar Monil, Doshi Rajkumar
Seth GS Medical College and KEM Hospital, Mumbai, India.
Department of Cardiology, University of California Riverside School of Medicine, Riverside, California.
Am J Cardiol. 2024 Jun 1;220:9-15. doi: 10.1016/j.amjcard.2024.03.021. Epub 2024 Mar 26.
The 2019 American College of Cardiology and American Heart Association guidelines regarding low-dose aspirin in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) indicate an increased risk of bleeding without a net benefit. The coronary artery calcium (CAC) score could be used to guide aspirin therapy in high-risk patients without an increased risk of bleeding. With this systematic review, we aimed to analyze studies that have investigated the role of CAC in primary prevention with aspirin. A total of 4 relevant studies were identified and the primary outcomes of interest were bleeding events and major adverse cardiac events. The outcomes of interest were stratified into 3 groups based on CAC scoring: 0, 1 to 99, and ≥100. A study concluded from 2,191 patients that with a low bleeding risk, CAC ≥100, and ASCVD risk ≥5% aspirin confers a net benefit, whereas patients with a high bleeding risk would experience a net harm, irrespective of ASCVD risk or CAC. All other studies demonstrated net benefit in patients with CAC ≥100 with a clear benefit. CAC scores correspond to calcified plaque in coronary vessels and are associated with graded increase in adverse cardiovascular events. Our review has found that in the absence of a significant bleeding risk, increased ASCVD risk and CAC score corelate with increased benefit from aspirin. A study demonstrated a decrease in the odds of myocardial infarction from 3 to 0.56 in patients on aspirin. The major drawback of aspirin for primary prevention is the bleeding complication. At present, there is no widely validated tool to predict the bleeding risk with aspirin, which creates difficulties in accurately delineating risk. Barring some discrepancy between studies, evidence shows a net harm for the use of aspirin in low ASCVD risk (<5%), irrespective of CAC score.
2019年美国心脏病学会和美国心脏协会关于低剂量阿司匹林在动脉粥样硬化性心血管疾病（ASCVD）一级预防中的指南指出，出血风险增加而无净获益。冠状动脉钙化（CAC）评分可用于指导高危患者的阿司匹林治疗，且不会增加出血风险。通过本系统评价，我们旨在分析研究CAC在阿司匹林一级预防中作用的研究。共确定了4项相关研究，主要关注的结局是出血事件和主要不良心脏事件。基于CAC评分，将关注的结局分为3组：0、1至99和≥100。一项对2191例患者的研究得出结论，在出血风险低、CAC≥100且ASCVD风险≥5%的情况下，阿司匹林有净获益，而出血风险高的患者无论ASCVD风险或CAC如何都会有净危害。所有其他研究均表明，CAC≥100的患者有明显的净获益。CAC评分与冠状动脉血管中的钙化斑块相对应，并与不良心血管事件的分级增加相关。我们的综述发现，在没有显著出血风险的情况下，ASCVD风险增加和CAC评分增加与阿司匹林获益增加相关。一项研究表明，服用阿司匹林的患者心肌梗死几率从3降至0.56。阿司匹林一级预防的主要缺点是出血并发症。目前，尚无广泛验证的工具来预测阿司匹林的出血风险，这给准确界定风险带来了困难。尽管研究之间存在一些差异，但证据表明，无论CAC评分如何，对于ASCVD低风险（<5%）的患者使用阿司匹林有净危害。
