title: Beyond Framingham risk factors and coronary calcification: does aortic valve calcification improve risk prediction? The Heinz Nixdorf Recall Study.
abstract: BACKGROUND
  Aortic valve calcification (AVC) is considered a manifestation of atherosclerosis. In this study, we investigated whether AVC adds to cardiovascular risk prediction beyond Framingham risk factors and coronary artery calcification (CAC).
  
  
  METHODS
  A total of 3944 subjects from the population based Heinz Nixdorf Recall Study (59.3±7.7 years; 53% females) were evaluated for coronary events, stroke, and cardiovascular disease (CVD) events (including all plus CV death) over 9.1±1.9 years. CT scans were performed to quantify AVC. Cox proportional hazards regressions and Harrell's C were used to examine AVC as event predictor in addition to risk factors and CAC.
  
  
  RESULTS
  During follow-up, 138 (3.5%) subjects experienced coronary events, 101 (2.6%) had a stroke, and 257 (6.5%) experienced CVD events. In subjects with AVC>0 versus AVC=0 the incidence of coronary events was 8.0% versus 3.0% (p<0.001) and the incidence of CVD events was 13.0% versus 5.7% (p<0.001). The frequency of events increased significantly with increasing AVC scores (p<0.001). After adjustment for Framingham risk factors, high AVC scores (3rd tertile) remained independently associated with coronary events (HR 2.21, 95% CI 1.28 to 3.81) and CVD events (HR 1.67, 95% CI 1.08 to 2.58). After further adjustment for CAC score, HRs were attenuated (coronary events 1.55, 95% CI 0.89 to 2.69; CVD events 1.29, 95% CI 0.83 to 2.00). When adding AVC to the model containing traditional risk factors and CAC, Harrell's C indices did not increase for coronary events (from 0.744 to 0.744) or CVD events (from 0.759 to 0.759).
  
  
  CONCLUSIONS
  AVC is associated with incident coronary and CVD events independent of Framingham risk factors. However, AVC fails to improve cardiovascular event prediction over Framingham risk factors and CAC.
authors: Department of Cardiology, West-German Heart Center Essen, University Duisburg-Essen, Essen, Germany.
authors: Hagen
authors: H
authors: Kälsch
authors: Biometry, and Epidemiology, Institute of Medical Informatics, University Duisburg-Essen, Essen, Germany.
authors: Nils
authors: N
authors: Lehmann
authors: Department of Cardiology, West-German Heart Center Essen, University Duisburg-Essen, Essen, Germany.
authors: Amir A
authors: AA
authors: Mahabadi
authors: Department of Cardiology, West-German Heart Center Essen, University Duisburg-Essen, Essen, Germany.
authors: Marcus
authors: M
authors: Bauer
authors: Department of Cardiology, West-German Heart Center Essen, University Duisburg-Essen, Essen, Germany.
authors: Kaffer
authors: K
authors: Kara
authors: Department of Cardiology, West-German Heart Center Essen, University Duisburg-Essen, Essen, Germany.
authors: Patricia
authors: P
authors: Hüppe
authors: Biometry, and Epidemiology, Institute of Medical Informatics, University Duisburg-Essen, Essen, Germany.
authors: Susanne
authors: S
authors: Moebus
authors: Department of Cardiology, Krankenhaus Bethanien, Moers, Germany.
authors: Stefan
authors: S
authors: Möhlenkamp
authors: Medical Faculty, Centre for Health and Society, Institute of Medical Sociology, University Clinic Düsseldorf, Düsseldorf, Germany.
authors: Nico
authors: N
authors: Dragano
authors: Cardioangiological Center Bethanien, Frankfurt/Main, Germany.
authors: Axel
authors: A
authors: Schmermund
authors: Medical Faculty, Institute of Clinical Epidemiology, University Halle-Wittenberg, Halle, Germany.
authors: Andreas
authors: A
authors: Stang
authors: Biometry, and Epidemiology, Institute of Medical Informatics, University Duisburg-Essen, Essen, Germany.
authors: Karl-Heinz
authors: KH
authors: Jöckel
authors: Department of Cardiology, West-German Heart Center Essen, University Duisburg-Essen, Essen, Germany.
authors: Raimund
authors: R
authors: Erbel
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000000981:diagnostic imaging; D000082882:Bicuspid Aortic Valve Disease; D002114:Calcinosis / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D016009:Chi-Square Distribution; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D018450:Disease Progression; D018572:Disease-Free Survival; D005260:Female; D005858:Germany / Q000453:epidemiology; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D061205:Vascular Calcification / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality