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Updated: May 20, 2025
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Published on: June 2, 2022
Association of Extracoronary Calcification and Incident Heart Failure in the Multiethnic Study of Atherosclerosis
Sandeep Brar1, Rahul Goli2, Joshua P Barrios2
1Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, San Francisco, California, USA.
Insights
Extracoronary calcification (ECC) is linked to a higher risk of heart failure (HF). This association is particularly strong for heart failure with preserved ejection fraction (HFpEF), suggesting ECC may aid risk assessment.
Area of Science:
- Cardiovascular Medicine
- Radiology
- Epidemiology
Background:
- Extracoronary calcification (ECC) is a recognized cardiovascular risk factor.
- The relationship between ECC and heart failure (HF) requires further investigation.
Purpose of the Study:
- To assess the association between ECC and the incidence of HF.
- To specifically examine the link between ECC and heart failure with preserved ejection fraction (HFpEF).
Main Methods:
- Utilized data from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort.
- Calculated an ECC score based on computed tomographic imaging of the aorta and heart valves.
- Employed multivariable Cox proportional hazards regression to analyze ECC and HF risk.
Main Results:
- The highest quartile of ECC score showed a 1.7-fold increased hazard for incident HF.
- ECC remained significantly associated with a 3-fold increased hazard for HFpEF after full adjustment.
- The association between ECC and overall HF risk was attenuated after accounting for coronary artery calcification.
Conclusions:
- ECC is independently associated with an increased risk of developing HF, especially HFpEF.
- ECC may serve as a valuable marker for improving cardiovascular risk prediction models for HF and HFpEF.
Background:
Extracoronary calcification (ECC) is a prevalent cardiovascular risk factor.
Objectives:
The aim of this study was to examine the association between ECC and heart failure (HF), including heart failure with preserved ejection fraction (HFpEF).
Methods:
MESA (Multi-Ethnic Study of Atherosclerosis) participants with computed tomographic imaging at baseline for calcification of the aortic valve, aortic root, mitral valve, and thoracic aorta were included. ECC score was calculated by rescaling Agatston scores from 0 to 1 for each ECC site and summing the rescaled scores. Multivariable Cox proportional hazards regression was performed to examine the association between ECC quartiles and incident HF.
Results:
Of all MESA participants, 3,617 (53.1%) and 3,192 (46.9%) had ECC scores of 0 and >0, respectively. During a mean follow-up period of 12.9 ± 4.2 years, 358 HF events were observed, 179 HF with reduced ejection fraction and 135 HFpEF. After controlling for demographics and risk factors, the highest ECC quartile (compared with the lowest quartile) had 1.7-fold greater hazard of incident HF (adjusted HR: 1.72 [95% CI: 1.16-2.55]; P = 0.007), though this was attenuated to borderline significance after additional adjustment for coronary artery calcification. In contrast for HFpEF, the highest ECC quartile (compared with the lowest quartile) remained independently and statistically significantly associated with 3-fold greater hazard of incident HFpEF (adjusted HR: 3.09 [95% CI: 1.45-6.60]; P = 0.003) after full adjustment, including for coronary artery calcification.
Conclusions:
ECC is associated with increased risk for HF, in particular HFpEF. If this finding is confirmed in other studies, ECC could help improve traditional risk factor estimation and clinical risk assessments for HF and HFpEF.
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