What question did this study set out to answer?

This research aims to explore how mitral annular calcification and coronary artery calcification relate to the risk of developing atrial fibrillation.

May 7, 2026Open Access

Mitral annular calcification, coronary artery calcification, and risk of incident atrial fibrillation in the multi-ethnic study of atherosclerosis (MESA)

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=6588). Intervention: Coronary artery calcification (CAC) and mitral annular calcification (MAC) vs. No CAC and no MAC. Primary outcome: Incident atrial fibrillation (HR 1.96).

PCParag Anilkumar ChevliWake Forest University SMSoroush MasrouriResearch Institute for Endocrine Sciences ARAlexander C. RazaviEmory University

Key Result

The joint presence of coronary artery and mitral annular calcification was associated with a 96% higher risk of incident atrial fibrillation compared to having neither.

Key Points

This research aims to explore how mitral annular calcification and coronary artery calcification relate to the risk of developing atrial fibrillation.
Assessment of CAC and MAC using cardiac computed tomography and Agatston scoring.
Four participant groups were established based on the presence of CAC and MAC.
Incident AF was identified through hospitalization records and Medicare claims, followed by multivariable-adjusted Cox proportional hazards models.
There were 1306 incident AF events among 6588 participants over a median follow-up of 16.5 years.
Participants with both CAC and MAC had a 96% higher risk of incident AF compared to those with no CAC or MAC.
Inclusion of CAC and MAC improved the CHARGE-AF risk score, with a C-statistic increase from 0.746 to 0.754 (p < 0.01).

Study Design

Type

Cohort (n=6,588)

Multicenter

Yes

Structured PICO

Does the presence of coronary artery calcification and mitral annular calcification increase the risk of incident atrial fibrillation in adults free of baseline cardiovascular disease?

Population

6,588 men and women aged 45-84 years from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort, free of clinically apparent cardiovascular disease and atrial fibrillation at baseline. The cohort includes four racial/ethnic groups (non-Hispanic White, African American, Hispanic, and Chinese American). Mean age 62 ± 10 years, 53% female.

Intervention

Presence of coronary artery calcification (CAC) and/or mitral annular calcification (MAC) assessed by non-contrast cardiac computed tomography and quantified by Agatston scoring.

Comparator

No coronary artery calcification (CAC) and no mitral annular calcification (MAC) (reference group).

Outcome

Incident atrial fibrillation (AF) identified through hospitalization records, Medicare claims, and study electrocardiograms over a median follow-up of 16.5 years.hard clinical

The combined presence of coronary artery calcification and mitral annular calcification identifies individuals at a substantially higher risk for incident atrial fibrillation and modestly improves risk prediction beyond traditional clinical models.

Main Result

Effect estimate: HR 1.96

Abstract

Background: Coronary artery calcification (CAC) and mitral annular calcification (MAC) reflect cardiovascular aging and systemic atherosclerosis and have each been associated with the risk of atrial fibrillation (AF).Objective: To examine the joint associations of CAC and MAC with incident AF in the Multi-Ethnic Study of Atherosclerosis (MESA).Methods: CAC and MAC were assessed using cardiac computed tomography and quantified by Agatston scoring.Participants were categorized into four groups: no CAC and no MAC (reference), CAC present without MAC, MAC present without CAC, both CAC and MAC present.Incident AF was identified through hospitalization records and Medicare claims.Multivariable-adjusted Cox proportional hazards models examined the association between CAC/MAC categories and incident AF.Improvement in AF risk prediction with the addition of CAC and MAC to Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE-AF) risk score was assessed using Harrell's C-statistic.Results: Among 6588 participants (mean age 62 10 years; 53% female) free of baseline AF, 1306 incident AF events occurred over a median follow-up of 16.5 years.Participants with both CAC and MAC present had the highest risk of AF.Compared with the reference group, CAC present without MAC, MAC present without CAC, and both CAC and MAC present were associated with 39%, 74%, and 96% higher risks of incident AF, respectively.Addition of CAC and MAC improved discrimination of the CHARGE-AF model (C-statistic 0.746 to 0.754; p < 0.01).Conclusions: CAC and MAC were jointly associated with incident AF, and their inclusion in a risk score improved AF risk prediction.

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