Prognostic role of cardiac calcifications in primary prevention: A powerful marker of adverse outcome highly dependent on underlying cardiac rhythm

Background: Increasing evidence exists regarding calcium detected in aortic cusps and/or mitral annulus (AOC_MAC) at transthoracic echocardiogram as a predictor of cardiovascular (CV) events and mortality.

Purpose: To verify whether AOC_MAC has a prognostic role in the setting of primary prevention independently of the presence of atrial fibrillation (AF).

Methods: All subjects consecutively referred from January 2011 to October 2014 to the Cardiovascular Centre for CV risk assessment in primary prevention were selected. AOC_MAC was assessed by transthoracic echocardiography. Primary study endpoint was a composite of CV hospitalizations/all-cause death.

Results: The 1389 study patients were 70 years old, 43% males, 24% had diabetes mellitus, 75% arterial hypertension, 56% dyslipidaemia. Of all, 997 (72%) were in sinus rhythm (SR), 392 (28%) in AF. Patients with AF were older and more frequently males, with larger atria than SR subjects. During a median follow-up of 32 months, 165 patients (12%) were hospitalized for CV cause, 68 (5%) died. The primary endpoint occurred more frequently in patients with than without AOC_MAC (18% vs 11%, p < 0.001). AF patients showed higher event-rate compared with patients in SR (20% vs 10%, respectively; p < 0.01). AOC_MAC emerged as an independent prognosticator of primary endpoint in SR patients (HR 1.74 [1.07-2.82], p = 0.02), together with increasing age and left ventricular hypertrophy, while AOC_MAC had no prognostic relevance in AF patients.

Conclusions: In subjects with multiple CV risk factors assessed in primary prevention, the presence of AF nullifies the prognostic power of AOC_MAC, on the contrary robustly confirmed in SR patients.