Aloha!

What recommendations would you recommend?

As a non-academic clinical physician, are there objective findings, on physical exam, or lab tests which i might be able to utilize which would allow me to make the most prudent recommendation?

Mahalo for your video presentation.

Madhup Joshi, MD 

Any therapy is associated with risk. 

Low dose aspirin for prevention of heart events in patients with atherosclerosis is clearly of value as the risk of death from MI is much greater than risk of death from bleeding. 

Low dose aspirin in subjects with no atherosclerosis is unlikely to have any value in preventing a heart attack because the individual is at such low risk.  The small possibility of a major bleeding event overshadows the immeasurably small risk of MI in atherosclerotisis free individuals. 

I see this as yet another in a very long line of reasons that we should be doing atherosclerosis imaging.  The presence of any calcium within coronary vessels increases one's risk of an MI by 3 times that risk predicted by conventional risk factors (MESA), a score >100 increases risk 7 times.  This should be a clear indication for low dose aspirin (plus other medical and lifestyle interventions).   

The absence of calcium in coronary vessels by EBT is associated with a 10 year risk of 1%.  With this level of risk, aspirin can only cause harm as you would need to put 3,000 subjects on ASA for ten years to maybe prevent one heart attack, or 3,000 subjects for 30 years to prevent one fatal heart attack.   The risk of dying from complications of ASA over 90,000 patient years exceeds 1!

 Conventional risk factors have been shown to be entirely too weak and unreliable to base therapy decisions upon, especially when these interventions have risks.   Primum non nocere