Aortic valve calcification and the presence, pattern and severity of subclinical coronary artery atherosclerosis in a middle-aged general population

Background Early aortic valve lesions in aortic sclerosis resemble atherosclerosis, with inflammatory cell infiltration, deposition of circulating lipids, and active calcification. However, data on the early stages of aortic valve calcification (AVC) and its relationship to coronary artery calcification (CAC) in the general population remain limited. Purpose To characterize the associations between AVC and the presence, pattern and severity of CAC in the Swedish CArdioPulmonary BioImage Study (SCAPIS). Methods SCAPIS enrolled 30,154 individuals aged 50-64 years randomly recruited from the general population between 2013 and 2018. Participants underwent non-contrast cardiac computed tomography (CT) and coronary CT angiography at six university hospitals in Sweden. AVC was assessed as present or absent, CAC severity was quantified using the Agatston score, and coronary atherosclerosis was characterized on a per-segment basis (no atherosclerosis, 1% to 49% stenosis, or ≥50% stenosis) with additional assessment of noncalcified plaque. Bicuspid aortic valves and previous aortic valve surgery were excluded from the analyses. Logistic regression was used to model the probability of AVC as a function of CAC presence (CAC score > 0) and CAC score categories (0, 1-10, 11-100, 101-400, and >400), with CAC = 0 as reference. Results A total of 28,642 participants were included (mean age 57.2±4.3 years, 51.9% women). The prevalence of AVC and CAC was 6.9% and 40.9%, respectively. Among those without CAC, the prevalence of AVC was 3.7%. AVC prevalence increased progressively across CAC categories (CAC score 1-10: 7.2%, 11-100: 9.8%, 101-400:14.6%, and >400: 23.9% (p<0.0001; Figure 1), particularly among men. Mean CAC score was higher in participants with AVC than in those without (201 vs. 52 Agatston units; p<0.001). On CCTA, participants with AVC more frequently had atherosclerosis in any coronary segment (69.0 vs. 40.9%), significant coronary stenosis in any segment (≥50%) (15.6 vs. 5.1%), presence of both calcified and non-calcified plaque in any segment (10.6 vs. 5.9%) but lower proportion of only non-calcified plaque (2.2% vs. 2.5%) compared with those without AVC (Figure 2). In analyses adjusted for age, sex, BMI, diabetes, hypertension, smoking, eGFR, LDL, lipid lowering treatment and previous cardiovascular disease, AVC showed a stepwise increase in odds across CAC severity (CAC 1-10: OR 1.6, 95% CI 1.3-1.8; 11-100: OR 2.0, 95% CI 1.7-2.2; 101-400: OR 2.7, 95% CI 2.3-3.1; >400: OR 4.1, 95% CI 3.4-4.9). Conclusions AVC in this middle-aged population cohort was associated with a substantially higher and more advanced coronary atherosclerotic burden, including mixed calcified and non-calcified plaque, beyond traditional risk factors alone. These findings suggest that AVC detected by CT should prompt careful cardiovascular risk assessment and management, rather than being regarded as a benign or isolated valvular finding.