Association of calcium density in the thoracic aorta with risk factors and clinical events

Eur Radiol. 2020 Jul;30(7):3960-3967. doi: 10.1007/s00330-020-06708-w. Epub 2020 Feb 25.


Objectives: In the ascending aorta, calcification density was independently and inversely associated with cardiovascular disease (CVD) risk prediction. Until now, the density of thoracic aorta calcium (TAC) was estimated as the Agatston score divided by the calcium area (DAG). We thought to analyze TAC density in a full Hounsfield unit (HU) range and to study its association with TAC volume, traditional risk factors, and CVD events.

Methods: Non-enhanced CT images of 1426 patients at intermediate risk were retrospectively reviewed. A calcium density score was estimated as the average of the maximum HU attenuation in all calcified plaques of the entire thoracic aorta (DAV).

Results: During a mean 4.0 years follow-up, there were 26 events for a total of 674 patients with TAC > 0. TAC volume and DAV were positively correlated (R = 0.72). The median DAV value was 457 HU (IQ 323-603 HU) and was exponentially related to DAG (R = 0.86). DAV was inversely associated with systolic pressure (p < 0.05), pulse pressure (p < 0.01), hypertension (p < 0.05), and 10-year FRS (p < 0.001) after adjusting for TAC volume. When TAC volume and DAV were included in a logistic model, a significant improvement was shown in CVD risk estimation beyond coronary artery calcium (CAC) (AUC = 0.768 vs 0.814, p < 0.05). In multivariable Cox models, TAC volume and DAV showed an independent association with CVD.

Conclusions: In intermediate risk patients, TAC density was inversely associated with several risk factors after adjustment for TAC volume. A significant improvement was observed over CAC when TAC volume and density were added into the risk prediction model.

Key points: • Calcifications in the aorta can be non-invasively assessed using CT images • A higher calcium score is associated with a higher cardiovascular risk • Measuring the calcifications size and the density separately can improve the risk prediction.

Keywords: Atherosclerosis; Calcium; Cardiovascular diseases; Thoracic aorta.

MeSH terms

  • Angiography / methods*
  • Aorta, Thoracic / diagnostic imaging*
  • Aorta, Thoracic / metabolism
  • Aortic Diseases / diagnosis*
  • Aortic Diseases / metabolism
  • Calcinosis / diagnosis*
  • Calcium / metabolism*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors


  • Calcium