Abstract
Coronary artery calcium scoring reliably identifies persons with subclinical coronary atherosclerosis who are at risk for major acute cardiac events. Aspirin guided by such enhanced risk stratification can be used to advance primary cardiovascular prevention. This approach has been recommended to prevent cardiac arrests in middle-aged men during marathons and sudden cardiac deaths during recreational sports activity in the elderly persons. These strategies are supported by demonstration of a 44% reduction in first heart attacks in healthy middle-aged men in the final report on aspirin in the Physicians’ Health Study and a 31% decrease in major acute cardiac events in persons at moderate risk with the addition of aspirin to the polypill in the TIPS-3, which are both randomized controlled primary prevention trials. Beyond preventing sports-related exertional cardiac events, aspirin use guided by coronary artery calcium scoring may reduce the risk for major acute cardiac events in patients with conditions in which inflammation promotes progressive coronary atherosclerosis, such as autoimmune illnesses and infection with human immunodeficiency virus. This strategy may furthermore be applicable in general medical practice to identify persons with subclinical coronary atherosclerosis for enhanced primary prevention with aspirin in the absence of contraindications.