Advances in primary cardiovascular prevention depend upon enhanced risk stratification. Gated coronary artery calcium CT scanning independently identifies persons at increased risk for major acute cardiac events including sudden death due to subclinical coronary atherosclerosis.  Low-dose aspirin use guided by such scoring has been recommended to reduce the transiently increased race-related risk for cardiac arrest based on a 44% reduction in first heart attacks in healthy middle-aged men in the final report on aspirin in the Physicians’ Health Study. This strategy may also decrease the age-related risk for sudden cardiac death during recreational sports activity in elderly persons, as supported by a 31% decrease in major acute cardiac events in persons at moderate risk with the addition of aspirin to the polypill (TIPS-3 trial). Beyond exercise-related applications, guided aspirin use is appropriate for patients with conditions conferring excess cardiovascular risk including severe psychiatric illness and infection with human immunodeficiency virus infection. Safe, inexpensive and available worldwide, aspirin use can close the disparities in access to preventive measures due to stigma associated with these conditions. Once accepted as a standard of care in primary care practice, aspirin use for persons with subclinical coronary heart disease may ameliorate the risk for untoward sudden cardiac deaths, which are the presenting symptom in up to 40% of fatalities due to coronary heart disease. 

Arthur J. Siegel, MD, is an associate professor of medicine at Harvard Medical School and a fellow in the American College of Physicians.  His research on Boston marathon runners has enhanced the safety of the sport, including evidence-based treatments for cerebral edema due to exercise-related hyponatremia and low-dose aspirin use to reduce the transiently increased race-related risk for cardiac arrest.