title: Coronary artery calcification outperforms thoracic aortic calcification for the prediction of myocardial infarction and all-cause mortality: the Heinz Nixdorf Recall Study.
abstract: BACKGROUND
  Thoracic aortic calcification (TAC) is associated with cardiovascular (CV) risk factors and prevalent coronary artery disease. We aimed to investigate whether TAC burden is associated with incident myocardial infarction (MI) and all-cause mortality in subjects without known coronary artery disease and to determine its predictive value for these endpoints.
  
  
  METHODS
  We used longitudinal data from the population-based prospective Heinz Nixdorf Recall Study. TAC and coronary artery calcification (CAC) scores were quantified from non-contrast enhanced electron beam computed tomography. Cox regression analysis was used to determine the association of TAC with incident MI or all-cause mortality, adjusting for CV risk factors and additionally for CAC-score in a separate step. Predictive value of TAC was assessed using Harrell's C index.
  
  
  RESULTS
  Overall, 4040 participants without known coronary artery disease (59.4 years, 47% male) were included in this analysis. During a mean follow-up of 8.0 ± 1.5 years, we observed 136 coronary events and 304 deaths. In subjects with TAC>0 vs TAC = 0, the incidence of nonfatal MI was 4.2% vs 2.0% (p < 0.001), and all-cause mortality was 8.9% vs 5.2% (p < 0.001). Risks for coronary events and for all-cause mortality increased significantly with increasing TAC-scores (p < 0.001). After adjustment for CV risk factors, body mass index (BMI) and CV medication, a unit increase of TAC on a logarithmic scale (log(TAC + 1)) remained independently associated with coronary events (hazard ratio (HR) (95% confidence interval (CI)): 1.06 (1.00-1.14), p = 0.03) and all-cause mortality (HR 1.06 (1.01-1.12), p < 0.01). After further adjustment for CAC-score (log(CAC + 1)), hazard ratios were attenuated for both endpoints (coronary events: 0.98 (0.91-1.05), p = 0.56, all-cause mortality: 1.03 (0.98-1.08), p = 0.33). When adding log(TAC + 1) to the model containing traditional risk factors and CAC, Harrell's C indices did not increase for coronary events (0.773-0.772, p = 0.66) or for all-cause mortality (0.741-0.743, p = 0.49).
  
  
  CONCLUSIONS
  TAC is associated with incident coronary events and all-cause mortality independent of traditional CV risk factors in the general population. TAC fails to improve event prediction over CAC in both coronary events and all-cause mortality.
authors: West-German Heart Center Essen, University Duisburg-Essen, Germany Hagen.Kaelsch@uk-essen.de.
authors: Hagen
authors: H
authors: Kälsch
authors: Institute of Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Germany.
authors: Nils
authors: N
authors: Lehmann
authors: Institute of Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Germany.
authors: Marie H
authors: MH
authors: Berg
authors: West-German Heart Center Essen, University Duisburg-Essen, Germany.
authors: Amir A
authors: AA
authors: Mahabadi
authors: West-German Heart Center Essen, University Duisburg-Essen, Germany.
authors: Paul
authors: P
authors: Mergen
authors: West-German Heart Center Essen, University Duisburg-Essen, Germany.
authors: Stefan
authors: S
authors: Möhlenkamp
authors: West-German Heart Center Essen, University Duisburg-Essen, Germany.
authors: Marcus
authors: M
authors: Bauer
authors: West-German Heart Center Essen, University Duisburg-Essen, Germany.
authors: Kaffer
authors: K
authors: Kara
authors: Institute for Medical Sociology, University of Düsseldorf, Germany.
authors: Nico
authors: N
authors: Dragano
authors: IUF-Leibniz Research Institute for Environmental Medicine, Germany; University of Düsseldorf, Germany.
authors: Barbara
authors: B
authors: Hoffmann
authors: Institute of Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Germany.
authors: Susanne
authors: S
authors: Moebus
authors: Cardioangiological Center Bethanien, Germany.
authors: Axel
authors: A
authors: Schmermund
authors: Institute of Clinical Epidemiology, University Halle-Wittenberg, Halle, Germany.
authors: Andreas
authors: A
authors: Stang
authors: Institute of Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Germany.
authors: Karl-Heinz
authors: KH
authors: Jöckel
authors: West-German Heart Center Essen, University Duisburg-Essen, Germany.
authors: Raimund
authors: R
authors: Erbel
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic; D001018:Aortic Diseases / Q000150:complications* / Q000000981:diagnostic imaging / Q000453:epidemiology; D002114:Calcinosis / Q000150:complications* / Q000000981:diagnostic imaging / Q000453:epidemiology; D002423:Cause of Death / Q000639:trends; D003324:Coronary Artery Disease / Q000150:complications* / Q000000981:diagnostic imaging / Q000453:epidemiology; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014057:Tomography, X-Ray Computed / Q000379:methods*
keywords: Thoracic aortic calcification; all-cause mortality; coronary artery calcification; myocardial infarction; risk prediction