WASHINGTON, April 14, 2025 (APMnews) – The presence of extracoronary calcification—defined as calcification of the thoracic aorta, left-sided heart valves, and aortic root—is associated with an increased risk of heart failure, particularly heart failure with preserved ejection fraction (HFpEF), according to the MESA study published in JACC: Heart Failure.
"Previous studies have shown that extracoronary calcification is an independent predictor of myocardial infarction, coronary artery disease, all-cause mortality, and any fatal or non-fatal cardiovascular event, including heart failure," stated Sandeep Brar from the Department of Epidemiology and Biostatistics at the University of California, San Francisco, and his colleagues.
"Coronary artery disease and hypertension are among the most common causes of left ventricular myocardial dysfunction, suggesting that the presence of extracoronary calcifications on routine imaging may help predict the onset of heart failure diagnoses."
In this study, based on the multi-ethnic MESA cohort, 6,809 participants aged 45 to 84 with baseline CT imaging data on calcification of the aortic valve, aortic root, mitral valve, and thoracic aorta were included.
Among them, 53.1% had an ECC (extracoronary calcification) score of 0 (no extracoronary calcification), and 46.9% had a score above zero (presence of extracoronary calcification), "demonstrating a high prevalence of extracoronary calcifications even among individuals without cardiovascular disease," the authors commented.
Over an average follow-up period of 12.9 years, 358 cases of heart failure were reported, including 179 cases of heart failure with reduced ejection fraction (HFrEF) and 135 cases of HFpEF.
Extracoronary calcification levels were divided into quartiles, with the first quartile serving as the reference and the fourth quartile representing the highest level of calcification.
The third quartile was associated with a 2.1-fold increased risk of heart failure, while the fourth quartile was linked to a 4.1-fold increase compared to the reference quartile.
After adjustment for various confounding variables and major risk factors, the fourth quartile remained independently and significantly associated with heart failure, with a 1.7-fold increased risk. However, the association was no longer significant after further adjustment for coronary artery calcification (CAC) score.
A gradual and positive association with 10-year predicted heart failure risk
Extracoronary calcification was also associated with a higher risk of HFpEF but not of HFrEF.
Specifically, participants in the fourth quartile had a 3.1-fold increased risk of HFpEF compared to those in the first quartile after adjusting for demographic data, risk factors, and CAC score.
However, the fourth quartile of extracoronary calcification was not significantly associated with increased heart failure risk after adjustment for all of these factors.
The authors also highlighted that high levels of extracoronary calcification predicted heart failure even among participants with low, intermediate, or high 10-year risk based on the ARIC risk score, showing a gradual and positive association.
"We demonstrate that identifying extracoronary calcifications, including valvular and aortic calcifications, in asymptomatic individuals can serve as a risk factor for the development of heart failure, particularly HFpEF," the authors concluded.
"Our study shows that extracoronary calcification may contribute to the prediction of incident heart failure beyond the clinical variables included in the ARIC risk score, which is the standard for heart failure risk prediction, thus demonstrating the additive utility of extracoronary calcification beyond existing risk scores and clinical risk factors."
Further research is needed to better understand the link between extracoronary calcification and HFpEF.
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