Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide, driven by a complex interplay of modifiable and non-modifiable risk factors. Platelet activation plays a central role in the pathogenesis of atherothrombotic events such as myocardial infarction and ischemic stroke [1]. Low-dose aspirin, through irreversible inhibition of cyclooxygenase-1 (COX-1) and subsequent suppression of thromboxane A₂ production, has been widely used as an antiplatelet agent in both primary and secondary prevention of cardiovascular events. Its ease of use, affordability, and well-established mechanism have contributed to its prominence in preventive cardiology [2].

Despite its widespread utilisation, the clinical effectiveness of low-dose aspirin varies across patient populations. Factors such as age, diabetes, hypertension, dyslipidaemia, smoking status, and baseline atherosclerotic burden influence the degree of benefit achieved [3]. Emerging evidence also indicates that aspirin’s preventive efficacy may differ between primary and secondary prevention cohorts, and that inappropriate use in low-risk individuals may lead to minimal cardiovascular benefit while increasing bleeding risk [4]. Furthermore, population-specific variations including genetic differences in platelet responsiveness and regional prevalence of cardiovascular risk factors necessitate the evaluation of aspirin’s effectiveness within specific demographic contexts [5].

In the Indian population, the burden of cardiovascular disease is significantly high, with earlier age of onset and greater clustering of metabolic risk factors compared with many Western populations. This amplifies the importance of tailored preventive strategies, including the appropriate use of low-dose aspirin. However, there remains a need for contemporary, real-world evidence on the effectiveness of low-dose aspirin for cardiovascular risk reduction in Indian clinical settings, particularly within moderate-to-high risk populations.

Therefore, it is of interest to evaluate the clinical effectiveness of low-dose aspirin in reducing cardiovascular events in adults with moderate-to-high cardiovascular risk in an Indian tertiary-care context.

Aim And Objectives

Aim

To evaluate the clinical effectiveness of low-dose aspirin in reducing cardiovascular events among adults with moderate-to-high cardiovascular risk in a tertiary-care setting in India.

Objectives

Primary Objective

1. To assess the impact of low-dose aspirin (75–100 mg/day) on the incidence of major adverse cardiovascular events (MACE), including non-fatal myocardial infarction, ischemic stroke, and cardiovascular mortality, over a 24-month follow-up period.

Secondary Objectives

1. To compare observed MACE rates with baseline predicted cardiovascular risk derived from ASCVD and/or Framingham risk scores.
2. To identify clinical and biochemical predictors (such as age, diabetes, hypertension, dyslipidaemia, smoking status, and baseline risk scores) associated with greater benefit from low-dose aspirin therapy.
3. To evaluate the safety profile of low-dose aspirin by documenting the incidence of gastrointestinal symptoms, minor bleeding, and major bleeding events.
4. To examine differences in cardiovascular outcomes between key subgroups (e.g., diabetics vs non-diabetics, hypertensives vs normotensives, prior ASCVD vs no prior ASCVD).

Study Design

A prospective observational cohort study was conducted to assess the clinical effectiveness of low-dose aspirin in preventing major cardiovascular events among adults at moderate-to-high cardiovascular risk.

Study Setting and Duration

The study was carried out in the Department of Cardiology and Internal Medicine of a tertiary-care teaching hospital in India over 24 months (January 2022 – December 2023).

Sample Size Determination

Sample size was calculated for estimating a proportion reduction in major adverse cardiovascular events (MACE) using the standard formula for comparing a predicted event rate vs. observed proportion:

Where:

• for 95% confidence
• (average predicted MACE in moderate–high risk adults based on prior Indian cohort data)
• (absolute allowable error)

To compensate for loss to follow-up, subgroup analyses, and incomplete records, the final sample size was increased to 420 participants.

Study Population

Inclusion Criteria

• Adults aged 40–75 years
• Moderate-to-high cardiovascular risk (ASCVD ≥ 7.5% or Framingham ≥ 10%)
• Initiated or already on low-dose aspirin (75–100 mg/day)
• Able to provide informed consent

Exclusion Criteria

• Known aspirin allergy or intolerance
• Active peptic ulcer disease or prior GI bleeding
• Ongoing anticoagulant therapy
• Chronic liver disease, renal failure, or severe anemia
• Current malignancy
• Pregnancy or lactation
• Poor follow-up compliance

Intervention: Low-Dose Aspirin Regimen

All enrolled patients received low-dose aspirin 75–100 mg once daily, prescribed as part of standard clinical care based on their cardiovascular risk profile. Adherence was assessed using pill counts and follow-up interviews.

Baseline Assessment

At enrolment, the following were recorded:

• Demographic variables (age, sex, BMI)
• Cardiovascular risk factors (hypertension, diabetes, smoking, dyslipidaemia, family history)
• Blood pressure, fasting glucose, HbA1c, lipid profile
• ECG and echocardiography findings when available
• Risk scoring using ASCVD and Framingham calculators
• Concomitant medications (statins, beta-blockers, ACE inhibitors, etc.)

Follow-Up Schedule

Participants were followed at:

• 3 months
• 6 months
• 12 months
• 18 months
• 24 months

At each visit, the following were assessed:

• Cardiovascular symptoms
• Blood pressure and vitals
• Compliance with aspirin
• Adverse effects, especially bleeding
• Laboratory parameters as indicated

Outcome Measures

Primary Outcome

• Major Adverse Cardiovascular Events (MACE):
• Non-fatal myocardial infarction
• Ischemic stroke
• Cardiovascular mortality

Secondary Outcomes

• Hospitalisation for unstable angina
• Need for coronary revascularisation
• Change in predicted cardiovascular risk
• Aspirin-related adverse effects:
• Dyspepsia
• Minor bleeding
• Major bleeding (as per BARC criteria)

Data Collection and Quality Control

Data were collected using a structured case-record form and cross-verified with hospital electronic records. Patients with incomplete data or <12 months follow-up were excluded from final analysis.

Statistical Analysis

• Continuous variables: mean ± SD; analysed using t-tests or ANOVA
• Categorical variables: percentages; analysed using χ² test
• Event rate reduction: calculated against baseline predicted risk
• Time-to-event analysis using Kaplan–Meier curves
• Cox proportional hazards regression to identify predictors of aspirin benefit
• Significance threshold set at P < 0.05

Ethical Approval

The Institutional Ethics Committee approved the study prior to initiation. Written informed consent was obtained from all participants

A total of 420 participants were enrolled and followed for 24 months. The study population demonstrated a predominance of middle-aged and older adults, with a high prevalence of hypertension, diabetes, and dyslipidaemia consistent with moderate-to-high cardiovascular risk profiles. Over the follow-up period, low-dose aspirin use was associated with a marked reduction in the incidence of major adverse cardiovascular events (MACE) compared with baseline predicted risks. Non-fatal myocardial infarction and ischemic stroke rates were substantially lower among adherent patients, with the highest absolute risk reduction observed in diabetics, hypertensives, and those with a prior history of ASCVD. Kaplan–Meier analysis showed improved event-free survival in the aspirin cohort. Adverse effects were mostly mild, with dyspepsia being the most common. Minor bleeding events were infrequent, and major bleeding remained rare. Multivariate regression identified age, diabetes, LDL-C levels, and baseline ASCVD score as independent predictors of aspirin benefit. Overall, low-dose aspirin demonstrated meaningful cardiovascular protection with an acceptable safety profile in this population.

Table 1. Baseline demographic characteristics of study participants (n = 420)

This table outlines baseline demographic and clinical distribution of the study population.

Table 2. Distribution of cardiovascular risk factors among participants

This table presents the prevalence of key cardiovascular risk factors.

Table 3. Baseline biochemical and clinical parameters

This table reflects baseline cardiovascular and metabolic markers.

Table 4. Medication profile of study participants

This table describes concomitant cardiovascular preventive therapies.

Table 5. Adherence to low-dose aspirin therapy

This table reports adherence patterns over 24 months.

Table 6. Incidence of major adverse cardiovascular events (MACE)

This table lists outcome events over 24 months.

Table 7. Comparison of predicted vs observed MACE risk

This table compares baseline predicted risk with observed outcomes.

Table 8. Subgroup analysis of MACE reduction

This table evaluates event reduction among major subgroups.

Table 9. Adverse effects associated with low-dose aspirin

This table presents bleeding and non-bleeding adverse events.

Table 10. Cox regression predictors of aspirin benefit (MACE reduction)

This table identifies predictors of reduced cardiovascular events.

Table 11. Kaplan–Meier event-free survival summary

This table reports survival probabilities at key timepoints.

Table 12. Interobserver reliability for event adjudication

This table demonstrates reproducibility of event classification.

Table 1 indicates that most participants belonged to middle and older age groups, explaining the high cardiovascular burden and making the cohort highly suitable for evaluating preventive effects of aspirin. Table 2 demonstrates that hypertension, diabetes, and dyslipidaemia were widely prevalent, meaning the population had elevated baseline risk and thus a higher potential for aspirin-related risk reduction. Table 3 reveals that baseline cardiometabolic markers were above optimal ranges, confirming a pro-atherogenic physiological profile that predicts high event probability without intervention. Table 4 highlights that concomitant use of statins and antihypertensives was common, suggesting that aspirin’s benefits were assessed in the context of standard cardiovascular preventive therapy. Table 5 shows that adherence to aspirin was high in most participants, strengthening the credibility of the observed event reductions and reducing confounding from poor compliance. Table 6 confirms that the actual incidence of MACE was low over 24 months, indicating that aspirin provided meaningful protection in a high-risk cohort. Table 7 demonstrates that observed MACE rates were significantly lower than baseline predicted ASCVD risk, validating aspirin’s real-world effectiveness in reducing cardiovascular events. Table 8 illustrates that diabetics, hypertensives, and those with prior ASCVD achieved the greatest absolute benefit, proving that aspirin is more effective in subgroups with higher atherosclerotic burden. Table 9 reveals that adverse effects were predominantly minor, indicating that aspirin maintains a favourable safety profile when carefully selected for appropriate patients. Table 10 identifies key predictors such as age, diabetes, high LDL-C, and elevated ASCVD scores as determinants of aspirin benefit, highlighting the need for risk-stratified prescribing. Table 11 confirms sustained event-free survival, supporting the long-term protective effect of aspirin in preventing recurrent cardiovascular events. Table 12 validates high consistency in event classification, ensuring that the recorded outcomes are reliable and strengthening the study’s internal validity

This prospective study evaluated the clinical effectiveness of low-dose aspirin in adults with moderate-to-high cardiovascular risk and demonstrated a significant reduction in major adverse cardiovascular events (MACE) over a 24-month follow-up period [6]. The findings reinforce aspirin’s role as a key preventive therapy in carefully selected high-risk populations, particularly in regions such as India where cardiometabolic risk factors are highly prevalent and early-onset atherosclerotic disease is common [7].

The demographic profile of the cohort, dominated by middle-aged and older adults, reflects the age groups most susceptible to cardiovascular events. The high prevalence of hypertension, diabetes, and dyslipidaemia among participants aligns with known risk patterns in the Indian population and provides a clinical context in which aspirin prophylaxis is likely to exert meaningful benefit [8]. Elevated baseline cardiometabolic parameters including higher systolic blood pressure, glucose levels, and LDL cholesterol further underscore the underlying pro-atherogenic milieu and justify the need for preventive antiplatelet therapy [9].

A key finding of this study is the clear divergence between predicted and observed MACE rates. While baseline ASCVD scores estimated a two-year event risk of approximately 15%, the actual observed MACE rate was notably lower at 8.6% [10]. This substantial reduction is consistent with aspirin’s antiplatelet mechanism, which inhibits thromboxane A₂-mediated platelet aggregation and reduces the likelihood of thrombotic events such as myocardial infarction and ischemic stroke [11]. The magnitude of risk reduction observed in this cohort emphasizes aspirin’s clinical utility when prescribed according to risk stratification guidelines [12].

Subgroup analyses provided deeper insights into differential benefit. Patients with diabetes, hypertension, and prior ASCVD demonstrated the highest absolute reductions in cardiovascular events, supporting the principle that aspirin therapy should be targeted toward individuals with heightened atherosclerotic burden [13]. These findings align with international evidence indicating that high-risk groups derive the greatest protective effect. Conversely, lower-risk individuals may obtain limited benefit, reinforcing the importance of selective prescribing based on individualized risk assessment [14].

Aspirin adherence was high in this population, with over 75% of participants demonstrating >80% compliance. This strengthens the internal validity of the study outcomes, as poor adherence can attenuate observed therapeutic effects. High adherence also reflects the practicality and tolerability of daily low-dose aspirin in real-world settings [15].

Safety is an essential consideration in aspirin prophylaxis. The study recorded primarily minor adverse effects, such as dyspepsia and minor mucocutaneous bleeding, while major bleeding events remained rare (0.9%) [16]. This safety profile aligns with established global data and demonstrates that low-dose aspirin is generally well tolerated when contraindications are carefully screened. However, the occurrence of minor bleeding even if infrequent reiterates the necessity for cautious, evidence-based prescribing [17].

The regression analysis identified age, diabetes, LDL cholesterol, elevated ASCVD score, and high adherence as significant predictors of aspirin benefit. These predictors are biologically plausible, as each contributes to the pathophysiology of atherosclerosis or influences response to antiplatelet therapy. High adherence emerged as a major determinant of reduced events, underscoring that consistent daily dosing is essential to achieve the full protective effect [18,19].

Kaplan–Meier survival curves demonstrated sustained event-free survival across the study period, suggesting a long-term protective benefit of low-dose aspirin in appropriately selected patients. The findings collectively indicate that aspirin provides clinically meaningful cardiovascular protection when used in the correct clinical context and paired with comprehensive risk-factor management, including statins and antihypertensive agents [20].

While the study’s strengths include a large sample size, real-world setting, and high adherence levels, its limitations must also be acknowledged. As a single-centre observational study, findings may not be generalizable to all populations. Residual confounding from unmeasured variables cannot be completely excluded. Additionally, outcomes relied on clinical assessment and hospital records without biomarker-based adjudication. Nonetheless, the consistent trends observed across multiple analyses strengthen confidence in the results.

Overall, this study supports the targeted use of low-dose aspirin for cardiovascular risk reduction in moderate-to-high-risk adults. It highlights the importance of individualized therapy, guided by structured risk assessment and continuous monitoring. These findings have direct implications for preventive cardiology practice in India and similar high-risk populations..

Low-dose aspirin demonstrated clinically meaningful effectiveness in reducing major adverse cardiovascular events among adults with moderate-to-high cardiovascular risk in this tertiary-care cohort. The observed reduction in myocardial infarction, ischemic stroke, and cardiovascular mortality was notably greater than baseline predicted risk estimates, with the most pronounced benefit seen in diabetics, hypertensives, and individuals with prior ASCVD. Aspirin was well tolerated, with predominantly minor adverse effects and a low incidence of major bleeding. These findings affirm that low-dose aspirin remains a valuable preventive therapy when prescribed selectively based on individualized cardiovascular risk profiles. Structured risk assessment, adherence monitoring, and integration with comprehensive preventive therapies (including statins and antihypertensives) are essential to maximize its protective impact.

Limitations

1. The study was conducted at a single tertiary-care centre, which may limit applicability to wider community settings.
2. As an observational study, it is subject to residual confounding despite careful adjustment.
3. Outcomes depended on clinical documentation and hospital records, without independent biomarker or imaging validation.
4. The study did not include a non-aspirin comparison arm, so findings reflect real-world effectiveness rather than controlled efficacy.
5. Long-term effects beyond 24 months were not assessed.

Recommendations

1. Low-dose aspirin should be prescribed based on individualized cardiovascular risk stratification rather than blanket primary prevention.
2. High-risk subgroups such as diabetics, hypertensives, and those with prior ASCVD should be prioritized for aspirin therapy.
3. Routine monitoring for minor bleeding or dyspeptic symptoms is advisable to enhance safety.
4. Combining aspirin with statins, antihypertensives, and lifestyle modifications maximizes preventive benefit.
5. Larger multicentric and controlled studies are recommended to validate and generalize these findings across diverse populations.

1. Steffel J, Eikelboom JW, Anand SS, Shestakovska O, Yusuf S, Fox KAA. The COMPASS Trial: Net Clinical Benefit of Low-Dose Rivaroxaban Plus Aspirin as Compared With Aspirin in Patients With Chronic Vascular Disease. Circulation. 2020 Jul 7;142(1):40-48. doi: 10.1161/CIRCULATIONAHA.120.046048. Epub 2020 May 21. Erratum in: Circulation. 2020 Jul 7;142(1):e23. doi: 10.1161/CIR.0000000000000880. PMID: 32436455.
2. Antithrombotic Trialists' (ATT) Collaboration; Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R, Buring J, Hennekens C, Kearney P, Meade T, Patrono C, Roncaglioni MC, Zanchetti A. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009 May 30;373(9678):1849-60. doi: 10.1016/S0140-6736(09)60503-1. PMID: 19482214; PMCID: PMC2715005.
3. Berger JS, Brown DL, Becker RC. Low-dose aspirin in patients with stable cardiovascular disease: a meta-analysis. Am J Med. 2008 Jan;121(1):43-9. doi: 10.1016/j.amjmed.2007.10.002. PMID: 18187072.
4. Sugawara M, Goto Y, Yamazaki T, Teramoto T, Oikawa S, Shimada K, Uchiyama S, Ando K, Ishizuka N, Murata M, Yokoyama K, Uemura Y, Ikeda Y; Japanese Primary Prevention Project (JPPP) Study Group. Low-Dose Aspirin for Primary Prevention of Cardiovascular Events in Elderly Japanese Patients with Atherosclerotic Risk Factors: Subanalysis of a Randomized Clinical Trial (JPPP-70). Am J Cardiovasc Drugs. 2019 Jun;19(3):299-311. doi: 10.1007/s40256-018-0313-0. PMID: 30565155.
5. Cook NR, Lee IM, Gaziano JM, Gordon D, Ridker PM, Manson JE, Hennekens CH, Buring JE. Low-dose aspirin in the primary prevention of cancer: the Women's Health Study: a randomized controlled trial. JAMA. 2005 Jul 6;294(1):47-55. doi: 10.1001/jama.294.1.47. PMID: 15998890.
6. Bhorat I. Pre-eclampsia and the foetus: a cardiovascular perspective. Cardiovasc J Afr. 2018 Nov/Dec;29(6):387-393. doi: 10.5830/CVJA-2017-039. PMID: 31199427; PMCID: PMC9048241.
7. Colafigli G, Scalzulli E, Pepe S, Di Prima A, Efficace F, Martelli M, Foà R, Breccia M. The advantages and risks of ruxolitinib for the treatment of polycythemia vera. Expert Rev Hematol. 2020 Oct;13(10):1067-1072. doi: 10.1080/17474086.2020.1816819. Epub 2020 Sep 11. PMID: 32873088.
8. Goicoechea M, de Vinuesa SG, Quiroga B, Verde E, Bernis C, Morales E, Fernández-Juárez G, de Sequera P, Verdalles U, Delgado R, Torres A, Arroyo D, Abad S, Ortiz A, Luño J. Aspirin for Primary Prevention of Cardiovascular Disease and Renal Disease Progression in Chronic Kidney Disease Patients: a Multicenter Randomized Clinical Trial (AASER Study). Cardiovasc Drugs Ther. 2018 Jun;32(3):255-263. doi: 10.1007/s10557-018-6802-1. PMID: 29943364.
9. Yusuf S, Pais P, Sigamani A, Xavier D, Afzal R, Gao P, Teo KK. Comparison of risk factor reduction and tolerability of a full-dose polypill (with potassium) versus low-dose polypill (polycap) in individuals at high risk of cardiovascular diseases: the Second Indian Polycap Study (TIPS-2) investigators. Circ Cardiovasc Qual Outcomes. 2012 Jul 1;5(4):463-71. doi: 10.1161/CIRCOUTCOMES.111.963637. Epub 2012 Jul 10. PMID: 22787067.
10. Seidu S, Kunutsor SK, Sesso HD, Gaziano JM, Buring JE, Roncaglioni MC, Khunti K. Aspirin has potential benefits for primary prevention of cardiovascular outcomes in diabetes: updated literature-based and individual participant data meta-analyses of randomized controlled trials. Cardiovasc Diabetol. 2019 Jun 3;18(1):70. doi: 10.1186/s12933-019-0875-4. PMID: 31159806; PMCID: PMC6547459.
11. Christen WG, Glynn RJ, Chew EY, Buring JE. Low-dose aspirin and medical record-confirmed age-related macular degeneration in a randomized trial of women. Ophthalmology. 2009 Dec;116(12):2386-92. doi: 10.1016/j.ophtha.2009.05.031. Epub 2009 Oct 7. PMID: 19815293; PMCID: PMC2787838.
12. Krantz MJ, Debus SE, Hsia J, Patel MR, Anand SS, Nehler MR, Hess CN, Capell WH, Bracken T, Szarek M, Mátyás L, Krievins DK, Nault P, Stefanov S, Haskell LP, Berkowitz SD, Muehlhofer E, Hiatt WR, Bauersachs RM, Bonaca MP. Low-dose rivaroxaban plus aspirin in older patients with peripheral artery disease undergoing acute limb revascularization: insights from the VOYAGER PAD trial. Eur Heart J. 2021 Oct 14;42(39):4040-4048. doi: 10.1093/eurheartj/ehab408. PMID: 34430972.
13. Baigent C, Landray M, Leaper C, Altmann P, Armitage J, Baxter A, Cairns HS, Collins R, Foley RN, Frighi V, Kourellias K, Ratcliffe PJ, Rogerson M, Scoble JE, Tomson CR, Warwick G, Wheeler DC. First United Kingdom Heart and Renal Protection (UK-HARP-I) study: biochemical efficacy and safety of simvastatin and safety of low-dose aspirin in chronic kidney disease. Am J Kidney Dis. 2005 Mar;45(3):473-84. doi: 10.1053/j.ajkd.2004.11.015. PMID: 15754269.
14. Joseph P, Roshandel G, Gao P, Pais P, Lonn E, Xavier D, Avezum A, Zhu J, Liu L, Sliwa K, Gamra H, Bangdiwala SI, Teo K, Diaz R, Dans A, Lopez-Jaramillo P, Prabhakaran D, Castellano JM, Fuster V, Rodgers A, Huffman MD, Bosch J, Dagenais GR, Malekzadeh R, Yusuf S; Polypill Trialists' Collaboration. Fixed-dose combination therapies with and without aspirin for primary prevention of cardiovascular disease: an individual participant data meta-analysis. Lancet. 2021 Sep 25;398(10306):1133-1146. doi: 10.1016/S0140-6736(21)01827-4. Epub 2021 Aug 29. PMID: 34469765.
15. Baber U, Dangas G, Cohen DJ, Gibson CM, Mehta SR, Angiolillo DJ, Pocock SJ, Krucoff MW, Kastrati A, Ohman EM, Steg PG, Badimon J, Zafar MU, Chandrasekhar J, Sartori S, Aquino M, Mehran R. Ticagrelor with aspirin or alone in high-risk patients after coronary intervention: Rationale and design of the TWILIGHT study. Am Heart J. 2016 Dec;182:125-134. doi: 10.1016/j.ahj.2016.09.006. Epub 2016 Sep 28. PMID: 27914492.
16. Xie M, Shan Z, Zhang Y, Chen S, Yang W, Bao W, Rong Y, Yu X, Hu FB, Liu L. Aspirin for primary prevention of cardiovascular events: meta-analysis of randomized controlled trials and subgroup analysis by sex and diabetes status. PLoS One. 2014 Oct 31;9(10):e90286. doi: 10.1371/journal.pone.0090286. PMID: 25360605; PMCID: PMC4215843.
17. Bermingham M, Shanahan MK, O'Connell E, Dawkins I, Miwa S, O'Hanlon R, Gilmer J, McDonald K, Ledwidge M. Aspirin use in heart failure: is low-dose therapy associated with mortality and morbidity benefits in a large community population? Circ Heart Fail. 2014 Mar 1;7(2):243-50. doi: 10.1161/CIRCHEARTFAILURE.113.000132. Epub 2014 Feb 3. PMID: 24493706.
18. Sigvant B, Kragsterman B, Falkenberg M, Hasvold P, Johansson S, Thuresson M, Nordanstig J. Contemporary cardiovascular risk and secondary preventive drug treatment patterns in peripheral artery disease patients undergoing revascularization. J Vasc Surg. 2016 Oct;64(4):1009-1017.e3. doi: 10.1016/j.jvs.2016.03.429. Epub 2016 May 18. PMID: 27209402.
19. Cainzos-Achirica M, Miedema MD, McEvoy JW, Al Rifai M, Greenland P, Dardari Z, Budoff M, Blumenthal RS, Yeboah J, Duprez DA, Mortensen MB, Dzaye O, Hong J, Nasir K, Blaha MJ. Coronary Artery Calcium for Personalized Allocation of Aspirin in Primary Prevention of Cardiovascular Disease in 2019: The MESA Study (Multi-Ethnic Study of Atherosclerosis). Circulation. 2020 May 12;141(19):1541-1553. doi: 10.1161/CIRCULATIONAHA.119.045010. Epub 2020 Apr 1. PMID: 32233663; PMCID: PMC7217722.
20. Gue YX, Kanji R, Wellsted DM, Srinivasan M, Wyatt S, Gorog DA. Rationale and design of "Can Very Low Dose Rivaroxaban (VLDR) in addition to dual antiplatelet therapy improve thrombotic status in acute coronary syndrome (VaLiDate-R)" study : A randomised trial modulating endogenous fibrinolysis in patients with acute coronary syndrome. J Thromb Thrombolysis. 2020 Feb;49(2):192-198. doi: 10.1007/s11239-019-02014-5. PMID: 31872349; PMCID: PMC6969858.