几十年来,阿司匹林一直是心血管疾病一级预防的基石,然而,它在一级预防中的使用近年来受到了挑战。根据最近的试验,2022年USPSTF指南降低了在一级预防中使用阿司匹林的建议,这些试验表明在一级预防中使用阿司匹林具有低到中性的益处和增加的出血风险。然而,这些试验纳入的患者患动脉粥样硬化性心血管疾病(ASCVD)的风险相对较低,出血风险较高,这可能导致试验结果为阴性.当根据个体风险个性化治疗时,预防ASCVD是理想的。冠状动脉钙(CAC)评分是动脉粥样硬化的有力标志,并以分级方式可靠地预测ASCVD风险。多项研究表明,使用CAC≥100来识别将从一级预防中使用阿司匹林中受益的患者。此外,aCAC=0确定阿司匹林会导致净伤害的患者。在从一级预防到二级预防的连续风险中,CAC可能确定亚临床ASCVD患者使用阿司匹林的风险水平。ACC/AHA2019一级预防指南建议使用CAC重新分类风险并指导他汀类药物和阿司匹林的个性化分配。尽管USPSTF过去没有认可CAC的使用,鉴于使用CAC指导包括阿司匹林在内的初级预防治疗的大量证据,在临床实践中,使用CAC来确定阿司匹林的获益超过其风险的斑块负担水平,并在一级预防中个性化分配阿司匹林似乎是合理的.未来评估预防性治疗作用的研究和随机试验应使用CAC评分进行风险分层。
Aspirin has been a cornerstone for primary prevention of cardiovascular disease for decades, however its use in primary prevention has been challenged in recent years. The 2022 USPSTF
guidelines lowered the recommendation for the use of aspirin in primary prevention based on the recent trials that demonstrated a low to neutral benefit and an increased bleeding risk with the use of aspirin in primary prevention. However, these trials enrolled patients at a relatively low risk for atherosclerotic cardiovascular disease (ASCVD) and higher bleeding risk which could have contributed to the negative results of the trials. ASCVD prevention is ideal when therapies are personalized based on individual risk. Coronary artery calcium (CAC) score is a robust marker of atherosclerosis and reliably predicts the ASCVD risk in a graded fashion. Several studies have demonstrated the use of a CAC≥100 to identify patients who will benefit from the use of aspirin in primary prevention. Furthermore, a CAC=0 identifies patients in whom aspirin would lead to net harm. In the continuum of risk from primary to secondary prevention, CAC is likely to identify the level of risk that warrants aspirin use in patients with subclinical ASCVD. The ACC/AHA 2019 primary prevention
guidelines recommend the use of CAC to reclassify risk and guide personalized allocation of statins and aspirin. Although the USPSTF has not endorsed the use of CAC in the past, given an extensive body of evidence for use of CAC to guide primary preventive therapies including aspirin, it seems reasonable to use CAC to identify the level of plaque burden at which the benefit of aspirin outweighs its risk in clinical practice and personalize theallocation of aspirin in primary prevention. Future studies and randomized trials assessing the role of preventive therapies should use CAC score for risk stratification.