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Calcification of the aortic wall indicates risk but not beyond current clinically used risk factors assessment

      Atherosclerosis of the aorta (aortic sclerosis) is a typical manifestation of the disease, which is frequently found in autopsy. According to Demer et al., three types of calcification can be distinguished: (1) atherosclerosis associated intimal calcification of the intima, (2) medial calcification/Mönckeberg type of sclerosis, and (3) genetic disorder related calcification [
      • Demer L.L.
      • Tintut Y.
      Inflammatory, metabolic, and genetic mechanisms of vascular calcification.
      ]. A recent review describes the process of vascular calcification from pathophysiology to biomarkers [
      • Evrard S.
      • Delanaye P.
      • Kamel S.
      • Cristol J.P.
      • Cavalier E.
      SFBC/SN joined working group on vascular calcifications. Vascular calcification: from pathophysiology to biomarkers.
      ]. Whereas the intimal calcification is typical for coronary atherosclerosis, the medial process is more pronounced in aortic sclerosis. The atherosclerosis and calcification process reduces the elastic properties of the aortic wall occurring during aging. Typical signs of this process are a continuous reduction of diastolic blood pressure as well as higher pulse pressure resulting in enhanced pulse wave velocity during ageing [
      • Shin M.C.
      • Lee M.Y.
      • Huang J.C.
      • Tsai Y.C.
      • Chen J.H.
      • Chen S.C.
      • Chang J.M.
      • Chen H.C.
      Association of brachial-ankle pulse wave velocity and cardiomegaly with aortic arch calcification in patients on hemodialysis.
      ]. As in this situation the blood pressure waveform is augmented, the measurement of central blood pressure may be preferable [
      • Vlachopoulos C.
      • Aznaouridis K.
      • O'Rourke M.F.
      • Safar M.E.
      • Baou K.
      • Stefanadis C.
      Prediction of cardiovascular events and all-cause mortality with central haemodynamics: a systematic review and meta-analysis.
      ], particularly in young individuals in whom the brachial artery demonstrates augmented systolic pressure, whereas the central pressure may be normal [
      • O'Rourke M.F.
      • Adji A.
      Guidelines on guidelines: focus on isolated systolic hypertension in youth.
      ]. Using computed tomography (CT), calcified aortic plaques can be detected, localized and quantified. Advantages and disadvantages as well as recommendations for use of CT have been described previously [
      • Erbel R.A.
      • Boyans V.
      • Boileau C.
      • Bossone E.
      • Bartolomeo R.D.
      • Eggebrecht H.
      • Evangelista A.
      • Falk V.
      • Frank H.
      • Gaemperli O.
      • Grabenwöger M.
      • Haverich A.
      • Iung B.
      • Manolis A.J.
      • Meijboom F.
      • Nienaber C.A.
      • Roffi M.
      • Rousseau H.
      • Sechtem U.
      • Sirnes P.A.
      • Allmen R.S.
      • Vrints C.J.
      ESC committee for practice guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC).
      ]. TAC and aortic root calcification are markers of coronary atherosclerosis, too [
      • Nafakhi H.
      • Al-Nafakh H.A.
      • Al-Mosawi A.A.
      Aortic root calcification: a possible imaging biomarker of coronary atherosclerosis.
      ]. The multi-ethnic study of atherosclerosis (MESA) [
      • Takasu J.
      • Katz R.
      • Nasir K.
      • Carr J.J.
      • Wong N.
      • Detrano R.
      • Budoff M.J.
      Relationships of thoracic aortic wall calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA).
      ] and the population-based Heinz Nixdorf Recall (HNR) study [
      • Kälsch H.
      • Lehmann N.
      • Möhlenkamp S.
      • Becker A.
      • Moebus S.
      • Schmermund A.
      • Stang A.
      • Mahabadi A.A.
      • Mann K.
      • Jöckel K.H.
      • Erbel R.
      • Eggebrecht H.
      ] used non-contrast CT scanning for coronary artery calcification (CAC) scoring and measured the thoracic aorta calcification (TAC) in two population cohorts between 45 (45) and 80 (75) years of age. Takasu et al. reported that only 26.8% of the male and 29.1% of the female participants out of 6814 subjects showed TAC > 0 [
      • Takasu J.
      • Katz R.
      • Nasir K.
      • Carr J.J.
      • Wong N.
      • Detrano R.
      • Budoff M.J.
      Relationships of thoracic aortic wall calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA).
      ]. The prevalence was dependent of the ethnicity of the subjects (32.4% in Chinese, 32.4% in White, 24.9% in Hispanic, and 22.4% in Black [
      • Takasu J.
      • Katz R.
      • Nasir K.
      • Carr J.J.
      • Wong N.
      • Detrano R.
      • Budoff M.J.
      Relationships of thoracic aortic wall calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA).
      ]). Kälsch et al. reported a prevalence of TAC > 0 in 63.1% of 4025 participants (65.2% in men and 61.7% in women) [
      • Kälsch H.
      • Lehmann N.
      • Möhlenkamp S.
      • Becker A.
      • Moebus S.
      • Schmermund A.
      • Stang A.
      • Mahabadi A.A.
      • Mann K.
      • Jöckel K.H.
      • Erbel R.
      • Eggebrecht H.
      ]. In all age groups, TAC was less often found in the ascending than descending aorta (42.9% and 56.6%, respectively). TAC was found in the ascending aorta only in 6.5% and in the descending aorta in 20.2% of the participants [
      • Kälsch H.
      • Lehmann N.
      • Möhlenkamp S.
      • Becker A.
      • Moebus S.
      • Schmermund A.
      • Stang A.
      • Mahabadi A.A.
      • Mann K.
      • Jöckel K.H.
      • Erbel R.
      • Eggebrecht H.
      ]. Quantification of TAC demonstrated higher values for TAC in men than in women, which persisted during aging [
      • Kälsch H.
      • Lehmann N.
      • Möhlenkamp S.
      • Becker A.
      • Moebus S.
      • Schmermund A.
      • Stang A.
      • Mahabadi A.A.
      • Mann K.
      • Jöckel K.H.
      • Erbel R.
      • Eggebrecht H.
      ]. In MESA, however, the differences between sexes were small and only significant for Chinese (p = 0.035) and Hispanic (p = 0.042) participants [
      • Takasu J.
      • Katz R.
      • Nasir K.
      • Carr J.J.
      • Wong N.
      • Detrano R.
      • Budoff M.J.
      Relationships of thoracic aortic wall calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA).
      ]. The amount of calcification showed an age and sex related distribution similar to CAC with an exponential curvature of the percentile distribution [
      • Kälsch H.
      • Lehmann N.
      • Möhlenkamp S.
      • Becker A.
      • Moebus S.
      • Schmermund A.
      • Stang A.
      • Mahabadi A.A.
      • Mann K.
      • Jöckel K.H.
      • Erbel R.
      • Eggebrecht H.
      ]. TAC = 0 and CAC = 0 were reported for MESA in 44% of 6418 participants [
      • Takasu J.
      • Budoff M.J.
      • O'Brien K.D.
      • Shavelle D.M.
      • Probstfield J.L.
      • Carr J.J.
      • Katz
      Relationship between coronary artery and descending thoracic aortic calcification as detected by computed tomography: the Multi-ethnic study of atherosclerosis.
      ], however, for HNR, only in 15.7% of 4025 subjects [
      • Kälsch H.
      • Lehmann N.
      • Möhlenkamp S.
      • Becker A.
      • Moebus S.
      • Schmermund A.
      • Stang A.
      • Mahabadi A.A.
      • Mann K.
      • Jöckel K.H.
      • Erbel R.
      • Eggebrecht H.
      ]. TAC showed a strong association with traditional risk factors as summarized by the Framingham risk score, which was 12.7% in those with TAC > 0 and 9.3% in those with TAC = 0 [
      • Kälsch H.
      • Lehmann N.
      • Möhlenkamp S.
      • Becker A.
      • Moebus S.
      • Schmermund A.
      • Stang A.
      • Mahabadi A.A.
      • Mann K.
      • Jöckel K.H.
      • Erbel R.
      • Eggebrecht H.
      ]. MESA reported that TAC was associated with hypertension and current smoking. Diabetes, total cholesterol, high density cholesterol, low density cholesterol, family history of premature coronary events and C-reactive protein increased with TAC > 0 [
      • Takasu J.
      • Katz R.
      • Nasir K.
      • Carr J.J.
      • Wong N.
      • Detrano R.
      • Budoff M.J.
      Relationships of thoracic aortic wall calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA).
      ]. In addition, the HNR study demonstrated that fine particulate matter (PM) air pollution, measured as particles of an aerodynamic diameter ≤ 2.5 μm, and night time noise were both independently associated with an increase in TAC by 10.1% (95% CI; 6.6–30.9) per 2.4 μg/m3 PM2.5 and 3.9% (95% CI; 0.0–8.0) per 5 dB night light noise [
      • Kälsch H.
      • Hennig F.
      • Moebus S.
      • Möhlenkamp S.
      • Dragano N.
      • Jakobs H.
      • Memmesheimer M.
      • Erbel R.
      • Jöckel K.H.
      • Hoffmann B.
      Heinz Nixdorf recall study investigative group. Are air pollution and traffic noise independently associated with atherosclerosis: the Heinz Nixdorf recall study.
      ]. This association underlines the importance of long-term exposure to air pollution and road traffic noise as a risk factor for atherosclerosis [
      • Kälsch H.
      • Hennig F.
      • Moebus S.
      • Möhlenkamp S.
      • Dragano N.
      • Jakobs H.
      • Memmesheimer M.
      • Erbel R.
      • Jöckel K.H.
      • Hoffmann B.
      Heinz Nixdorf recall study investigative group. Are air pollution and traffic noise independently associated with atherosclerosis: the Heinz Nixdorf recall study.
      ].

      Keywords

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