In primary prevention, low-dose aspirin can be considered for which scenario?

• A. Diabetes with a 10-year ASCVD risk of 12%
• B. Diabetes with a 10-year ASCVD risk of 4%
• C. CAC score over 100 in a person with no increased bleeding risk
• D. Any patient over 80 with no risk factors

Answer: (A)

Risk-benefit balance in primary prevention guides aspirin use. The key is whether a person’s estimated 10-year ASCVD risk is high enough to potentially outweigh the bleeding risk from adding daily aspirin. In people with diabetes, a 10-year ASCVD risk around or above 10% is a threshold where low-dose aspirin can be considered, especially when the bleeding risk is low and there’s a shared decision with the patient. A 12% risk fits this scenario well, making daily low-dose aspirin a reasonable consideration, assuming no significant bleeding risk factors.

A 4% 10-year risk falls below the threshold where routine aspirin is advised, so it’s not typically recommended. A CAC score over 100 suggests higher risk, but decisions about aspirin still hinge on the overall risk assessment and bleeding risk; CAC alone isn’t the sole deciding factor. An 80-year-old with no risk factors generally has limited or uncertain net benefit from aspirin due to higher bleeding risk and reduced likelihood of ASCVD event reduction translating into meaningful improvement.