Density and morphology of coronary artery calcium for the prediction of cardiovascular events: insights from the Framingham Heart Study

Borek Foldyna*, Parastou Eslami, Jan-Erik Scholtz, Kristin Baltrusaitis, Michael T. Lu, Joseph M. Massaro, Ralph B. D'Agostino, Maros Ferencik, Hugo J. W. L. Aerts, Christopher J. O'Donnell, Udo Hoffmann

*Corresponding author for this work

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Objectives To investigate the association between directly measured density and morphology of coronary artery calcium (CAC) with cardiovascular disease (CVD) events, using computed tomography (CT). Methods Framingham Heart Study (FHS) participants with CAC in noncontrast cardiac CT (2002-2005) were included and followed until 2016. Participants with known CVD or uninterpretable CT scans were excluded. We assessed and correlated (Spearman) CAC density, CAC volume, and the number of calcified segments. Moreover, we counted morphology features including shape (cylindrical, spherical, semi-tubular, and spotty), location (bifurcation, facing pericardium, or facing myocardium), and boundary regularity. In multivariate Cox regression analyses, we associated all CAC characteristics with CVD events (CVD-death, myocardial infarction, stroke). Results Among 1330 included participants (57.8 +/- 11.7 years; 63% male), 73 (5.5%) experienced CVD events in a median follow-up of 9.1 (7.8-10.1) years. CAC density correlated strongly with CAC volume (Spearman's rho = 0.75; p <0.001) and lower number of calcified segments (rho = - 0.86; p <0.001; controlled for CAC volume). In the survival analysis, CAC density was associated with CVD events independent of Framingham risk score (HR (per SD) = 2.09; 95%CI, 1.30-3.34; p = 0.002) but not after adjustment for CAC volume (p = 0.648). The extent of spherically shaped and pericardially sided calcifications was associated with fewer CVD events accounting for the number of calcified segments (HR (per count) = 0.55; 95%CI, 0.31-0.98; p = 0.042 and HR = 0.66; 95%CI, 0.45-0.98; p = 0.039, respectively). Conclusions Directly measured CAC density does not predict CVD events due to the strong correlation with CAC volume. The spherical shape and pericardial-sided location of CAC are associated with fewer CVD events and may represent morphological features related to stable coronary plaques.

Original languageEnglish
Pages (from-to)6140-6148
Number of pages9
JournalEuropean Radiology
Issue number11
Publication statusPublished - Nov 2019


  • Multi-detector computed tomography
  • Coronary artery calcium
  • Coronary artery disease
  • Atherosclerosis
  • Cardiovascular system
  • RISK


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