Association between Aspirin Therapy and Clinical Outcomes in Patients with Non-Obstructive Coronary Artery Disease: A Cohort Study

Abstract

BackgroundPresence of non-obstructive coronary artery disease (CAD) is associated with increased prescription of cardiovascular preventive medications including aspirin. However, the association between aspirin therapy with all-cause mortality and coronary revascularization in this population has not been investigated.Methods and FindingsAmong the cohort of individuals who underwent coronary computed tomography angiography (CCTA) from 2007 to 2011, 8372 consecutive patients with non-obstructive CAD (1-49% stenosis) were identified. Patients with statin or aspirin prescription before CCTA, and those with history of revascularization before CCTA were excluded. We analyzed the differences of all-cause mortality and a composite of mortality and late coronary revascularization (>90 days after CCTA) between aspirin users (n=3751; 44.8%) and non-users. During a median of 828 (interquartile range 385–1,342) days of follow-up, 221 (2.6%) mortality cases and 295 (3.5%) cases of composite endpoint were observed. Annualized mortality rates were 0.97% in aspirin users versus 1.28% in non-users, and annualized rates of composite endpoint were 1.56% versus 1.48%, respectively. Aspirin therapy was associated with significantly lower risk of all-cause mortality (adjusted HR 0.649; 95% CI 0.492–0.857; p=0.0023), but not with the composite endpoint (adjusted HR 0.841; 95% CI 0.662–1.069; p=0.1577). Association between aspirin and lower all-cause mortality was limited to patients with age ≥65 years, diabetes, hypertension, decreased renal function, and higher levels of coronary artery calcium score, low-density lipoprotein cholesterol and high-sensitivity C-reactive protein.ConclusionsAmong the patients with non-obstructive CAD documented by CCTA, aspirin is associated with lower all-cause mortality only in those with higher risk.

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

“…This is despite the available evidence suggesting that individuals with nonobstructive CAD have an increased risk for adverse clinical outcomes compared with patients with normal coronary arteries 4, 7, 8. Moreover, there is evidence that medical therapy (in particular, aspirin and statins) improves clinical outcomes in patients with nonobstructive CAD 17, 18. Consistent with this, we found important differences in clinical outcomes in patients receiving OMT, particularly being at lower risk for all‐cause hospitalization compared with those who were not receiving OMT.…”

Use of Coronary Computed Tomographic Angiography to Guide Management of Patients With Coronary Disease

“…For symptomatic patients with suspected coronary artery disease, the presence and severity of coronary artery disease identified on CCTA is associated with the increased use of preventive therapies such as aspirin and statin therapies 13 , 14 as well as lifestyle modification 14 , 15 . A single-center registry of 8,372 patients with nonobstructive coronary artery disease identified by CCTA also showed that statin therapy was associated with lower mortality, but aspirin therapy was only associated with lower mortality in high-risk patients 16 , 17 . However, all of these observational studies have many potential biases, including case selection bias and confounding by treatment allocation.…”

Comparison of mid‐ to long‐term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta‐analysis of randomized trials

“…The use of CCTA could result in increased use of medications and invasive procedures, because this test reveals the presence of coronary atherosclerosis even in the subclinical stage . Of note, the increased use of preventive medications in patients with nonobstructive CAD detected by CCTA leads to improvements in lipid profile and blood pressure control; and, moreover, it can reduce the risk of mortality and cardiovascular events . Therefore, the clinical outcomes following CCTA should be assessed on a long‐term basis, because the prognosis can be determined by the intensified preventive medications and the increased use of ICA and coronary revascularization following anatomical testing, as well as the potential missed diagnosis by functional testing.…”

“…27,28 Of note, the increased use of preventive medications in patients with nonobstructive CAD detected by CCTA leads to improvements in lipid profile and blood pressure control; and, moreover, it can reduce the risk of mortality and cardiovascular events. [29][30][31] Therefore, the clinical outcomes following CCTA should be assessed on a long-term basis, because the prognosis can be determined by the intensified preventive medications and the increased use of ICA and coronary revascu- the Better Evaluation of Acute Chest Pain with Computed Tomography Angiography (BEACON) trial with 1 month of follow-up, 4 and several cohort studies with 1 or 2 months of follow-up duration. [33][34][35] Considering the possible increase in the use of invasive procedures driven by CCTA results, as well as its potential benefit for prevention of future cardiovascular events, the impact of the initial diagnostic approach should be assessed on a long-term basis.…”