Long-Term Prognostic Implications of Thoracic Aortic Calcification on CT Using Artificial Intelligence–Based Quantification in a Screening Population: A Two-Center Study

<b>BACKGROUND.</b> The importance of including the thoracic aortic calcification (TAC), in addition to coronary artery calcification (CAC), in prognostic assessments has been difficult to determine, partly due to greater challenge in performing standardized TAC assessments. <b>OBJECTIVE.</b> The purpose of this study was to evaluate long-term prognostic implications of TAC assessed using artificial intelligence (AI)-based quantification on routine chest CT in a screening population. <b>METHODS.</b> This retrospective study included 7404 asymptomatic individuals (median age, 53.9 years; 5875 men, 1529 women) who underwent nongated noncontrast chest CT as part of a national general health screening program at one of two centers from January 2007 to December 2014. A commercial AI program quantified TAC and CAC using Agatston scores, which were stratified into categories. Radiologists manually quantified TAC and CAC in 2567 examinations. The role of AI-based TAC categories in predicting major adverse cardiovascular events (MACE) and all-cause mortality (ACM), independent of AI-based CAC categories as well as clinical and laboratory variables, was assessed by multivariable Cox proportional hazards models using data from both centers and concordance statistics from prognostic models developed and tested using center 1 and center 2 data, respectively. <b>RESULTS.</b> AI-based and manual quantification showed excellent agreement for TAC and CAC (concordance correlation coefficient: 0.967 and 0.895, respectively). The median observation periods were 7.5 years for MACE (383 events in 5342 individuals) and 11.0 years for ACM (292 events in 7404 individuals). When adjusted for AI-based CAC categories along with clinical and laboratory variables, the risk for MACE was not independently associated with any AI-based TAC category; risk of ACM was independently associated with AI-based TAC score of 1001-3000 (HR = 2.14, <i>p</i> = .02) but not with other AI-based TAC categories. When prognostic models were tested, the addition of AI-based TAC categories did not improve model fit relative to models containing clinical variables, laboratory variables, and AI-based CAC categories for MACE (concordance index [C-index] = 0.760-0.760, <i>p</i> = .81) or ACM (C-index = 0.823-0.830, <i>p</i> = .32). <b>CONCLUSION.</b> The addition of TAC to models containing CAC provided limited improvement in risk prediction in an asymptomatic screening population undergoing CT. <b>CLINICAL IMPACT.</b> AI-based quantification provides a standardized approach for better understanding the potential role of TAC as a predictive imaging biomarker.