Sim, Marc, Webster, James, Smith, Cassandra, Saleem, Afsah, Gilani, Syed Zulqarnain, Toro-Huamanchumo, Carlos J, Suter, David, Figtree, Gemma, Lagendijk, Anne Karine, Duncan, Emma L, Schultz, Carl, Szulc, Pawel, Hung, Joseph, Lim, Wai H, Raina, Parminder, Bondonno, Nicola P, Woodman, Richard, Hodgson, Jonathan M, Kiel, Douglas P, Prince, Richard L, Leslie, William D, Kemp, John P, Harvey, Nicholas C, Schousboe, John T and Lewis, Joshua R (2026) Automated abdominal aortic calcification scores and atherosclerotic cardiovascular disease in the UK biobank imaging study. JACC Advances, 5 (3), 102570. (doi:10.1016/j.jacadv.2025.102570).
Abstract
Background
Abdominal aortic calcification (AAC) is a subclinical measure of atherosclerotic cardiovascular disease (ASCVD). AAC can be captured on lateral spine images obtained from bone density machines during routine osteoporosis screening. Identifying individuals with AAC provides a new opportunity to prevent disease progression.
Objectives
The aim of the study was to externally validate a machine learning-derived AAC 24-point algorithm (ML-AAC24) with incident ASCVD.
Methods
Middle-aged individuals from the UK Biobank Imaging Study with lateral spine images, obtained via dual-energy x-ray absorptiometry, were included. ML-AAC24 scores were grouped as low (<2), moderate (2 to <6), and high (≥6). Linked health records were used to identify ASCVD-associated events, including hospitalizations and death.
Results
Among 53,611 participants (52% female; mean age 65 years), 78.2% had low, 16.4% had moderate, and 5.4% had high ML-AAC24. After excluding people with prevalent ASCVD or missing data, 1,163 (2.3%) of 50,923 people had an incident ASCVD event over a median follow-up of 4.1 [3.0-5.5] years. In age- and sex-adjusted analysis, compared to those with low ML-AAC24, those with moderate (HR: 1.80 [95% CI: 1.57-2.08]) and high ML-AAC24 (HR: 2.87 [95% CI: 2.39-3.44]) had a higher HR for incident ASCVD. Results remained comparable after adjustment for established ASCVD risk factors. Consistent patterns were observed when considering incident coronary artery disease, myocardial infarction, and stroke.
Conclusions
Assessing ML-AAC24 on lateral spine images offers a new and promising screening method to identify people with higher risk of incident ASVD events.
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