Asymptomatic Incidental Extensive Aortic Calcification in a 75-year-old Male: Clinical Implications and Surveillance Strategies

The case of a 75-year-old male who had a routine chest X-ray and was found to have a calcified aorta is significant for several reasons and a discussion regarding calcific aortic changes, their clinical implications, and the necessity of surveillance in asymptomatic individuals. The abdomen X-ray of the patient showed continued calcification [Figures 1 and 2].Figure 1: Full calcification of abdominal aortaFigure 2: Full calcification of thoracic aortaIt is a common radiographic finding and noted in both chest and abdominal X-rays, particularly in elderly patients. Calcification of the aorta may potentially manifest from a number of factors, such as atherosclerosis, aging, or previous inflammatory processes. This patient did not exhibit symptoms, and at 6 months of follow-up, no target organ diseases were found, which is a good sign in this population. The extensive calcification which we had is relatively rare. Calcification of large arteries is a crucial risk factor for cardiovascular diseases, yet it remains underdiagnosed due to a lack of routine monitoring, obscuring its prevalence in the general population. Utilizing machine learning methods, we quantified abdominal aortic calcification (AAC) within the UK Biobank imaging cohort and conducted an extensive analysis of its genetic, biochemical, and epidemiological risk factors. Our genetic association study identified three novel loci associated with AAC – fibroblast growth factor-9, NAV9, and apolipoprotein E–alongside the replication of a known association at the TWIST1/HDAC9 locus. Our results show that AAC is prevalent, affecting approximately 10% of adults over 40 with significant hydroxyapatite accumulation (Kauppila score >3). Importantly, AAC presence strongly predicts future cardiovascular events, including precerebral artery stenosis (HR 1.5), myocardial infarction (HR 1.3), and ischemic heart disease (hazard ratio [HR] 1.3), as well as chronic obstructive pulmonary disease (HR 1.3). The HR for myocardial infarction from elevated AAC (HR 1.4) is similar to that of hypercholesterolemia (HR 1.4), and the majority of those with AAC (98%) lack known preexisting risk factors, such as chronic kidney disease and diabetes. These findings highlight the urgent need for increased awareness and monitoring of AAC in the general population due to its significant cardiovascular risks.[1] Previous studies have demonstrated that the prevalence of aortic calcification increases dramatically with age; a chest radiograph and an echocardiograph were performed. Aortic calcification was observed in 74/290 (25.5%) patients. Patients with calcification were mostly female (67.6%) and older (71.8 ± 1.9 years), whereas patients without calcification were younger (59.0 ± 0.79) and of both sexes (51.85% female).[2] Often, the presence of calcification has been used as a marker or risk factor for cardiovascular disease; such patients would be at higher risk for an event like myocardial infarction or stroke. However, the actual utility of these findings in predicting events remains a matter of ongoing research. It must be noted that not all aortic calcification cases imply immediate clinical concern. Aortic stiffness, typically associated with calcification, does correlate with cardiovascular risk, but its direct clinical implications can vary very widely between patients. Some may remain asymptomatic and have few or no negative outcomes over the years. However, the presence of a calcified aorta might be associated with other pathologies, such as kidney disease or peripheral artery disease, which must be carefully monitored.[3-5] In a study of 289 hypertensive patients with a mean age of 63.87 years, 53.6% exhibited a renal resistive index (RRI) ≥0.70. Those with elevated RRI were older and showed a higher prevalence of aortic arch calcification (AAC) and left ventricular hypertrophy. A multiple linear regression analysis revealed a significant predictive relationship between AAC and RRI (β =0.053; P < 0.001). These findings indicate a strong, independent association between AAC and renal hemodynamics in hypertensive patients.[6] The management approach to incidental findings of aortic calcification in older adults would include routine follow-up and cardiovascular risk assessment. This 75-year-old male has been reassuring because he did not present with clinical symptoms, and there is no evidence of involvement of target organs. It, however, often necessitates very extensive evaluations including monitoring of blood pressure, lipid profiling, and screening for diabetes as these have been robust interplayers with the overall health status in relation to the cardiovascular health status. In our case, the whole of the aorta is calcified which is rare. Furthermore, with ongoing studies, there has been a need to understand not only the occurrence of cardiovascular events but also its implications on the vascular health of an individual. Some studies[7] are even showing correlations between calcification and cognitive decline, but still, the underlying mechanisms are obscure. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.