Key result
Carotid intima-media thickness is biologically distinct from atherosclerosis, and aspirin would likely reduce cardiovascular risk in high-risk patients with true atherosclerosis measured by plaque burden.
This commentary highlights that carotid intima-media thickness should not be conflated with true atherosclerosis, and that carotid plaque burden is a more appropriate measure for assessing cardiovascular risk and the potential benefit of aspirin.
There was a fatal flaw in the review by Hu et al.,(Hu et al., 2022) who reported that aspirin did not slow progression of carotid intima-media thickness (IMT) and did not reduce the risk of cardiovascular events in patients with carotid IMT. They studied IMT, which is biologically, (Spence, 2015) genetically, (Pollex and Hegele, 2006) and pathologically (Finn et al., 2010) distinct from atherosclerosis. (Spence, 2020) The journal Atherosclerosis has established a policy that IMT must not be referred to as "preclinical atherosclerosis". It should be referred to as ""arterial injury" or "arteriopathy", not "atherosclerosis". (Raggi and Stein, 2020) IMT is a much weaker predictor of myocardial infarction (Johnsen et al., 2007) or stroke (Mathiesen et al., 2011) than carotid plaque burden, measured as total plaque area (TPA). Indeed, carotid plaque burden is strongly associated with, (Sillesen et al., 2012) and as predictive of cardiovascular risk (Baber et al., 2015) as a coronary calcium score. IMT is neither. (Sillesen et al., 2012, Baber et al., 2015 Among patients referred for cardiovascular prevention whose TPA was in the top quartile (> 119 mm 2 ), the 5-year risk of stroke, myocardial infarction or vascular death was 19.5%, after adjusting for baseline risk factors. (Spence et al., 2002) It is extremely likely that aspirin would reduce cardiovascular risk in such high-risk patients with true atherosclerosis.
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J. David Spence (2023) conducted an editorial in Asymptomatic carotid atherosclerosis. Aspirin was evaluated. Carotid intima-media thickness is biologically distinct from atherosclerosis, and aspirin would likely reduce cardiovascular risk in high-risk patients with true atherosclerosis measured by plaque burden.