Heart Vessels (2012) 27:135142
DOI 10.1007/s00380-011-0129-1
ORIGINAL ARTICLE
Aortic arch calcification evaluated on chest X-ray is a strong
independent predictor of cardiovascular events in chronic
hemodialysis patients
Tomoko Inoue Tetsuya Ogawa Hideki Ishida
Yoshitaka Ando Kosaku Nitta
Received: 8 November 2010 / Accepted: 18 February 2011 / Published online: 18 March 2011
Springer 2011
Abstract Vascular calcification is associated with car-
diovascular disease in hemodialysis (HD) patients. Some
reports have previously shown that simple assessment of
aortic calcification using plain radiography is associated
with cardiovascular (CV) events; however, these studies
simply assessed whether aortic calcification was present or
absent only, without considering its extent. Here, we
evaluated the validity of grading aortic arch calcification
(AoAC) to predict new CV events. We retrospectively
reviewed chest X-rays in 212 asymptomatic HD patients
who underwent measurement of pulse wave velocity
(PWV) in 2006 without a past history of CV events. The
extent of AoAC was divided into four grades (03). Among
these subjects, the follow-up of CV events in 197 patients
was completed. At baseline, AoAC grade was positively
associated with age, dialysis vintage, PWV and parathyroid
hormone levels, and negatively correlated with body
weight and body mass index. Arterial stiffness, as deter-
mined by PWV, was also correlated with increasing AoAC
grade. Eighty-nine CV events in total occurred during a
mean follow-up period of 69 45 months. With multi-
variate adjustment, KaplanMeier analysis showed that the
incidence was significantly higher in patients with higher
AoAC grade (grades 2 and 3) than in those with grade 0 or
T. Inoue  T. Ogawa  K. Nitta (&)
Department of Medicine, Kidney Center,
Tokyo Womens Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo 162-8666, Japan
e-mail: knitta@kc.twmu.ac.jp
H. Ishida  Y. Ando
Kidney Center, Hidaka Hospital, Takasaki,
Gunma 370-0001, Japan
1 (p = 0.013, log-rank test). Multivariate Cox proportional
hazards analyses showed the predictive values of AoAC
grade were significant (hazard ratio 1.512; p = 0.0351).
AoAC detectable on chest X-ray is a strong independent
predictor of CV events in accordance with PWV. Risk
stratification by assessment of AoAC may provide impor-
tant information for management of atherosclerotic disease
in HD patients.
Keywords Chest radiography  Vascular calcification 
Hemodialysis  Mortality  Cardiovascular disease
Introduction
Cardiovascular (CV) disease is the major cause of death in
patients with chronic kidney disease (CKD) [1]. Recently,
vascular calcification in the coronary arteries and the aorta
has been recognized as an important risk factor for car-
diovascular disease in hemodialysis (HD) patients [2].
Vascular calcification is very common in end-stage renal
disease (ESRD), especially in HD patients [3]. The
mechanisms of vascular calcification are hyperphosphate-
mia and elevated calcium (Ca) 9 phosphate (P) products
[4, 5]. There are numerous experimental and clinical data.
First, we now have a clear idea that calcification of both
intimal atherosclerotic lesions and the medial vessels layer
is associated with cardiovascular mortality in HD patients
[6, 7]. Second, there is better evidence that vascular smooth
muscle cells can become chondrocyte or osteoblast-like
and lay down and mineralize collagen and non-collagenous
proteins in arteries [8]. Third, over 20 null mutations in
mice have arterial calcifications [9]. This confirms that
key proteins regulate or prevent vascular calcification.
Vascular calcification induces stiffening of the vessel wall
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and reduces vascular compliance, which has been found to
be predictive of cardiovascular mortality [10, 11].
The extent of vascular calcification can be quantified
with electron beam tomography (EBCT) [12] and multi-
detector CT (MDCT) [13]. Chest radiography is a common
non-invasive, and relatively inexpensive screening test that
is performed on HD patients for the examination of the
heart, and its value is unquestionable in routine health risk
assessment. Moreover, it is routinely ordered during dial-
ysis therapy to examine the cardiothoracic ratio (CTR).
Iribarren and colleagues [14] observed an independent
association between aortic arch calcification (AoAC) seen
on chest radiography and the presence of coronary artery
disease after retrospectively reviewing a large health
maintenance organization patient database [15, 16]. How-
ever, data on the clinical use of findings derived from chest
radiography analysis in HD patients are scarce.
We have recently reported the validity and usefulness of
assessment of AoAC grade, as determined by a simple
chest X-ray [17]. AoAC grade was significantly associated
with clustering of traditional risk factors. However, it is
still unknown whether AoAC grade is a sensitive predictor
of CV events. The purpose of the present study was to
determine the validity of AoAC grade as an independent
predictor of CV events in chronic HD patients.
Methods
Study population
There were 212 chronic HD patients (dialysis duration
[6 months) at Hidaka Hospital Kidney Center, Takasaki,
Japan, during January 2006 to December 2009. The HD
patients with known myocardial infarction, transient
ischemic attack, stroke, cerebral hemorrhage, peripheral
artery disease, heart failure, and severe CV diseases were
excluded. Of these, patients with acute illness, significant
infection, or malignancy were excluded. Of the remaining
patients, 197 (male/female = 122/75, mean age 66.3
12.0 years) gave informed consent for evaluating a chest
radiograph, as described next, and were investigated in the
present study. The enrolled patients underwent stable reg-
ular hemodialysis using bicarbonate dialysate.
At baseline, a chest radiograph of each patient was
obtained. They comprised a non-selected sample of
patients from the Kidney Center in Hidaka Hospital with-
out a selection bias. All patients completed a detailed
health history questionnaire just prior to follow-up of CV
events, and this study was restricted to asymptomatic
subjects with no history of CV events. However, we could
not rule out the asymptomatic patients with coronary dis-
ease because of no history of coronary angiography.
123
Heart Vessels (2012) 27:135142
Patients were then followed-up for 4 years, and relation-
ships between baseline data and outcomes were assessed
statistically. Data and causes of death were obtained by
reviewing hospital record forms. In patients who moved to
other dialysis units, we reviewed questionnaire forms filled
out by the attending physicians at the Hidaka Hospitals
Kidney Center. This study was approved by the ethics
review committee of the hospital. During the follow-up
period, 89 of 197 patients experienced CV events.
Assessment of aortic arch calcification
We performed a retrospective review of 197 patients
undergoing dialysis therapy. Two radiologist (one spe-
cializing in chest radiography) independently reviewed all
chest radiographs obtained from HD patients studied.
Radiographs were assessed for the presence of AoAC using
a specific scale as previously described [17]. The scale,
which was divided into 16 circumferences, was attached to
the aortic arch on chest radiography and then the number of
sectors with calcification was divided by 16 (Fig. 1). Aortic
arch calcification score (AoACS) was calculated after
being multiplied by 100 to express the results as a per-
centage. This value was as the indicator of the ACC. Our
previous study confirmed that AoACS was highly corre-
lated with aortic arch calcification volume evaluated by
multi-slice computer tomography (r = 0.635, p \ 0.001)
[17].
AoAC extent was divided into four grades according to
the following categorization. Briefly, we scored the extent
of calcification in the aortic arch as follows: grade 0,
AoACS = 0%; grade 1, AoACS = 14%; grade 2, AoACS =
59%; grade 3, AoACS[10%.
Laboratory measurements
Blood was drawn just before starting a dialysis session in a
fasting state. Serum albumin, calcium, phosphate, total
cholesterol, high-density lipoprotein (HDL) cholesterol,
triglyceride, blood sugar, C-reactive protein (CRP), and the
concentration of hemoglobin were measured by using
routine laboratory methods. Mean values of three mea-
surements during the 3 months before chest radiography
were used for analysis. Serum intact parathyroid hormone
(PTH) was measured once at the time of radiography. Body
mass index (BMI) was calculated dividing dry weight (kg)
by body height (m)2.
Clinical status of all subjects was evaluated by means of
routine clinical examination before the regular HD session.
Systolic and diastolic blood pressure was measured with a
mercury sphygmomanometer with the patient in the supine
position after 1015 min of rest, and mean values for
1 month were used for the analysis.
Heart Vessels (2012) 27:135142
Fig. 1 Evaluation of aortic arch
calcification on chest
radiography. AoAC extent was
divided into four grades
according to the categorization
Pulse wave velocity measurements
PWV was measured using a volume-plethysmographic
apparatus (Form/ABI; Omron-Colin Co., Ltd., Komaki,
Aichi, Japan). Details of the methodology have been
described elsewhere [18]. Occlusion and monitoring cuffs
were placed snugly around both sides of the upper and
lower extremities, with patients in the supine position.
Then, pressure waveforms of the brachial and tibial arteries
were recorded after 15 min of bed rest using an automatic
waveform analyzer. The validation of this method has been
reported previously [19].
Clinical outcomes
Subjects in this study were continuously monitored for
the occurrence of CV events. In the present study, the
CV events according to our definition were specified
clearly as coronary heart disease (CHD); angina pectoris
(AP); criteria of AP were defined by presence of chest
symptom and/or typical ST-T change in ECG, myocardial
infarction (MI), cerebrovascular disease (CVD); transient
ischemic attack (TIA), stroke, cerebral hemorrhage,
peripheral artery disease (PAD), heart failure (HF), and
CV death. Individual diagnoses were classified according
to the 9th International Classification of Disease (ICD-9)
codes.
Statistical analysis
Differences between the groups were analyzed using
ANOVA for continuous variables and v2 test for categorical
137
variables. To determine the factors related to AoAC grade,
multivariate regression stepwise analysis was used. In the
follow-up of CV events, event-free survival was analyzed
using the KaplanMeier curve and log-rank test. Hazard
ratios (HRs) for CV events were analyzed using a multi-
variate Cox proportional hazards regression. Data in the text,
tables, and figures are expressed as mean standard devi-
ation (SD). A p value \ 0.05 was considered statistically
significant.
Results
Patient characteristics
Among 197 patients, the follow-up of CV events in 89
patients was completed. Therefore, to evaluate the predictive
value of each factor against CV events, we analyzed all data
of these 89 patients in this study. AoAC grades of the subjects
(n = 197) with completed follow-up of new CV events were
distributed as follows: grade 0 (27/90 = 30.0%), grade 1
(30/53 = 56.6%), grade 2 (25/43 = 58.1%), and grade 3
(7/11 = 63.6%). Baseline characteristics of the total subjects
and of the subjects with each grade are shown in Table 1.
Because the number of subjects with grade 3 was small
(n = 11), we combined grades 2 and 3 for the following
analyses.
The AoAC grade was positively associated with age
(p = 0.0001), dialysis vintage (p = 0.0374), PWV (p \
0.0001) and intact PTH (p = 0.0072), and negatively cor-
related with body weight (p = -0.0126) and body mass
index (p = -0.0374).
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138 Heart Vessels (2012) 27:135142

Table 1 Baseline characteristics of hemodialysis patients according to AoAC

Total Grade 0 Grade 1 Grade 2 Grade 3 p value

Number (male/female) 197 (122/75) 90 (56/34) 53 (34/19) 43 (26/17) 11 (6/5) 0.9386

Age (years) 66.3 12.0 62.2 12.5 68.8 10.8 70.4 10.0 72.0 10.1 0.0001
Vintage (years) 13.9 7.7 12.9 7.3 12.9 7.6 16.4 7.7 16.9 9.4 0.0374
Atherosclerotic risk factors (%)
Hypertension 92 (46.7%) 37 (41.1%) 28 (52.8%) 21 (48.8%) 6 (54.5%) 0.5297
Diabetes 63 (32.0%) 32 (35.6%) 20 (37.7%) 10 (23.3%) 1 (9.1%) 0.1392
Dyslipidemia 95 (48.2%) 46 (51.1%) 22 (41.5%) 21 (48.8%) 6 (54.5%) 0.6962
Anthropometric measurements
Height (cm) 160.0 8.5 160.9 8.6 160.2 8.3 158.7 7.8 157.5 11.2 0.4216
Weight (kg) 55.3 11.5 58.1 12.0 52.0 10.3 53.9 10.0 52.9 14.5 0.0126
Body mass index (kg/m2) 21.5 3.7 22.4 4.0 20.2 3.3 21.3 3.1 20.9 3.3 0.0059
Medical measurements
Systolic BP (mmHg) 137.7 24.3 136.5 23.6 138.4 26.4 139.7 23.7 135.7 25.2 0.8907
Diastolic BP (mmHg) 79.0 12.6 80.1 12.2 77.8 11.9 79.2 13.7 74.2 14.7 0.4264
Pulse pressure (mmHg) 58.7 16.5 56.4 15.2 60.6 19.1 60.5 15.5 61.5 17.3 0.3542
PWV (cm/s) 1933.5 650.9 1779.6 433.6 1839.6 470.1 2262.8 830.9 2358.5 1287.3 \0.0001
Laboratory measurements
T-cholesterol (mg/dl) 152.3 34.4 155.6 37.6 147.8 28.0 147.6 29.5 166.0 47.7 0.2339
HDL-cholesterol (mg/dl) 43.3 12.8 44.0 12.9 42.4 11.6 43.0 13.1 43.8 16.6 0.9175
Triglyceride (mg/dl) 112.1 64.9 123.0 72.0 103.4 60.8 98.9 51.7 116.5 61.7 0.1486
Blood sugar (mg/dl) 140.2 50.4 143.6 53.3 142.1 53.8 134.2 43.4 126.5 31.6 0.5938
Calcium (mg/dl) 8.8 0.9 8.7 0.9 8.7 0.8 9.0 0.9 9.0 1.0 0.4598
Phosphorus (mg/dl) 6.0 1.2 6.1 1.3 6.0 1.0 6.1 1.2 5.8 1.0 0.7594
Intact-PTH (pg/ml) 229.8 142.3 209.6 123.8 213.2 120.5 263.3 157.4 341.9 237.5 0.0072
C-reactive protein (mg/dl) 0.4 0.7 0.4 0.9 0.3 0.6 0.4 0.6 0.3 0.3 0.8895
Albumin (mg/dl) 3.8 0.3 3.8 0.3 3.7 0.3 3.7 0.3 3.8 0.2 0.3585
Hemoglobin (g/dl) 10.2 1.0 10.2 1.0 10.1 0.9 10.2 1.1 10.3 0.5 0.9290
Anti-hypertensive drugs (%)
ACE inhibitors/ARBs 87 (44.2%) 40 (44.4%) 24 (45.3%) 20 (46.5%) 3 (27.3%) 0.7059
CCBs 116 (58.9%) 55 (61.1%) 32 (60.4%) 22 (51.2%) 7 (63.6%) 0.7068
Alpha/beta-blockers 72 (36.5%) 31 (32.2%) 19 (35.8%) 16 (34.9%) 6 (54.5%) 0.6309
Anti-hyperlipidemia drugs (%)
Statin 14 (7.1%) 5 (5.6%) 6 (11.3%) 3 (7.0%) 0 (0.0%) 0.4581
AoAC aortic arch calcification, BP blood pressure, PWV pulse wave velocity, HDL high-density lipoprotein, PTH parathyroid hormone,
ACE angiotensin-converting enzyme, ARB angiotensin receptor blocker, CCB calcium channel blocker

Correlates of AoAC grade Association between AoAC and CV events

As shown in Table 2, multiple regression analysis was
performed to determine the factors related to AoAC grade.
Statistically significant correlates of AoAC grade were age
(coefficient b = 0.203, p = 0.034), PWV (coefficient
b = 0.278, p = 0.001) and intact PTH (coefficient
b = 0.224, p = 0.001). The severity of AoAC grade was
significantly associated with an increase in PWV, sug-
gesting the patients with high AoAC grade had increased
arterial stiffness (Fig. 2).
A total of 89 new CV events occurred during a mean
follow-up period of 69 45 months among 197 patients.
These CV events included 12 strokes (seven cerebral
infarctions, three cerebral hemorrhages and two TIA), 54
CHD (53 AP and one MI), six HF and 17 PAD. Twenty-
three percent of subjects who had CHD underwent cor-
onary artery procedures (12 PCI and one CABG). We
differentiated the CV outcomes according to AoAC
grade.

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Heart Vessels (2012) 27:135142 139

Table 2 Multiple regression analysis of AoAC grade and signifi-

cantly associated variables
b t value p value

Age (years) 0.203 2.142 0.034

Sex (male: 1, female: 0) -0.062 -0.615 0.539
Vintage (years) 0.142 1.895 0.060
Height (cm) 0.087 0.242 0.809
Weight (kg) -0.187 -0.302 0.763
Body mass index (kg/m2) 0.082 0.172 0.864
Systolic BP (mmHg) -0.173 -1.140 0.256
Pulse pressure (mmHg) 0.221 1.359 0.176
PWV (cm/s) 0.278 3.555 0.001
T-cholesterol (mg/dl) -0.059 -0.687 0.493 Fig. 3 KaplanMeier event-free survival analysis of all cardiovas-
HDL-cholesterol (mg/dl) -0.042 -0.466 0.642 cular events according to AoAC grade. The incidence of CV events
was significantly higher in patients with higher AoAC grade (grade
Triglyceride (mg/dl) -0.076 -0.806 0.421 2 ? 3) than those with grade 0 or 1 (p = 0.0341) after adjustment for
Blood sugar (mg/dl) -0.134 -1.736 0.084 age, dialysis vintage, prevalence hypertension, and dyslipidemia
Calcium (mg/dl) 0.013 0.175 0.861
Phosphorus (mg/dl) 0.050 0.684 0.495
Table 3 Multivariate analysis with Cox proportional hazards models
Intact-PTH (pg/ml) 0.224 3.267 0.001
for cardiovascular events. Multivariate Cox proportional analysis
C-reactive protein (mg/dl) -0.049 -0.682 0.496 showed each predictive value of several factors for CV events using
Albumin (mg/dl) -0.022 -0.250 0.803 each laboratory parameter
Hemoglobin (g/dl) 0.132 1.720 0.087 Variable Hazard ratio 95% CI p value
AoAC aortic arch calcification, BP blood pressure, PWV pulse wave
velocity, HDL high-density lipoprotein, PTH parathyroid hormone Age (/year) 1.044 1.0101.078 0.0105
Gender (male) 0.773 0.4041.481 0.4381
Vintage (/year) 0.993 0.9541.033 0.7246
Total cholesterol (/mg/dl) 1.007 0.9971.017 0.1538
HDL-cholesterol (/mg/dl) 0.980 0.9521.009 0.1735
Systolic BP (/mmHg) 0.994 0.9821.007 0.3487
Body mass index (/kg/m2) 1.116 1.0231.219 0.0139
Blood sugar (/mg/dl) 0.998 0.9921.005 0.5997
PWV (/cm/s) 1.046 1.0061.086 0.0220
Calcium (/mg/dl) 1.214 0.8291.777 0.3188
Phosphorus (/mg/dl) 0.811 0.6021.091 0.1657
Intact-PTH (/pg/dl) 0.999 0.9971.001 0.3797
Albumin (/mg/dl) 0.495 0.1661.471 0.2057
C-reactive protein (/mg/dl) 0.961 0.6691.381 0.8299
Hemoglobin (/g/dl) 1.063 0.7621.482 0.7188
AoAC grade (2 ? 3) 1.512 1.0292.222 0.0351
CV cardiovascular, HDL high-density lipoprotein, BP blood pressure,
PWV pulse wave velocity, PTH parathyroid hormone, AoAC aortic
arch calcification
Fig. 2 Association between pulse wave velocity and AoAC grade in
hemodialysis patients. PWV was positively correlated with AoAC
grade Multivariate Cox proportional hazards analysis

As shown in Table 3, we evaluated the predictive value of

KaplanMeier analysis showed that the incidence of CV
events was significantly higher in patients with higher
AoAC grade (grades 2 ? 3) compared to those with AoAC
grade 0 or 1 (log-rank test; p = 0.013) (Fig. 3). There were
no sex-specific differences in any group.
each factor, such as age, gender, dialysis vintage, BMI,
hemoglobin, biochemical measurements, PWV and AoAC
grade, against CV events. In multivariate analysis using
each laboratory parameter, statistical significance was
found not only for increasing age but also for the

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presence of AoAC grades 2 ? 3 (HR 1.512, 95% CI
1.0292.222, p = 0.0351). The predictive power of AoAC
grade was weaker than that of higher PWV. Unexpect-
edly, higher BMI is most significantly associated with CV
events.
Discussion
Vascular calcification is a type of advanced atherosclerosis
in HD patients. Especially progressive arterial stiffness
resulting from calcification makes the management of
hemodynamics more difficult in these patients. We have
previously demonstrated the validity and usefulness of
semi-quantitative estimation of AoAC grade using chest
X-ray examination, which is less expensive and is easy to
follow-up routinely [17]. Among traditional risk factors,
AoAC grade was significantly correlated with older age
and higher intact PTH. In addition, AoAC grade was
associated with PWV. Therefore, we evaluated the effec-
tiveness of AoAC grade to predict new CV events using
well-treated outpatients without any symptoms and past
history. This study showed the usefulness of AoAC grade
as an independent predictor of new CV events. The result
suggests an advantage of this simple non-invasive evalua-
tion of AoAC detectable on plain X-ray, as opposed to
some recent highly technical procedures like MDCT.
If the level of calcification in the aorta predicts future
CV events, it should be considered which area in the
abdominal aorta or aortic arch is favorable and sensitive to
evaluate the extent of calcification. First, there is strong
evidence that radiographic abdominal aortic calcification
predicts CV events in huge populations during long-term
follow-up. A report demonstrated that a significant corre-
lation was found in the 933 CORD study participants with
plain abdominal X-ray during a period of 22 years [20].
Okuno et al. [21] also reported that the presence of
abdominal aortic calcification is significantly associated
with CV mortality in 515 HD patients (hazard ratio 2.07;
95% confidence interval 1.213.56; p \ 0.01). These
findings suggest valuable evaluation of abdominal aortic
calcification using abdominal X-ray. On the other hand, as
similar to the extent of calcification in the abdominal aorta,
it is unclear whether the calcified level in the aortic arch is
also a good predictor. There are relatively few reports
regarding the predictive value of AoAC against CV events,
although many previous studies have shown a positive
association of CV events with abdominal aortic calcifica-
tion. One possible explanation is that it is not easier to
evaluate calcium deposition semi-quantitatively in the
aortic arch as compared to that in the abdominal aorta. A
report handling with population-based cohort has showed
that the presence of AoAC was independently associated
123
Heart Vessels (2012) 27:135142
with an increased risk of CV mortality (hazard ratio 2.556;
95% confidence interval 1.0066.490; p \ 0.05) [22],
suggesting that the present results are consistent with this
evidence. However, that study evaluated whether AoAC
was present or absent using chest X-ray without consid-
ering the extent of calcification. There are several advan-
tages and differences of our study as compared to the
previous report. Our assessment by AAC grading certified
a strong predictive value of higher AoAC grade (grades
2 ? 3) against incident CV events more precisely. How-
ever, AoAC grade 1 had no statistical significance of pre-
dictive value compared to grade 0. This result suggests that
trivial calcium deposition in aortic arch only may not be a
noticeable CV risk. Hashimoto et al. [15] recently con-
firmed that the AoAC grade was significantly correlated
with the calcified level in abdominal aorta using two
independent non-invasive examinations. In fact, huge dif-
ferences in the hemodynamic state are found between
patients with trivial AoAC and those with severe AoAC.
Therefore, it is recommended at least to consider the AoAC
grade in routine clinical work.
Arterial stiffness and increased PWV are known to be
induced by vascular calcification. PWV measured in large
elastic arteries could be another indirect method for the
quantification of vascular calcification. We previously
reported that PWV is significantly correlated with the grade
of aortic calcification in chronic HD patients [23]. In
addition, we have shown that AoAC and PWV are inde-
pendent factors for diastolic left ventricular dysfunction in
these patients [18]. Several possible mechanisms for the
association between arterial stiffness and vascular calcifi-
cation can be hypothesized. First, arterial calcification may
induce arterial wall stiffness and increased PWV [24]. A
previous study in adult HD patients reported an association
between 25-hydroxy vitamin D deficiency and arterial
stiffness [25]. Secondly, increased arterial stiffness may
cause vessel wall damage and atherosclerosis [26]. Thirdly,
changes in the intrinsic properties of arterial wall by arte-
rial remodeling may contribute to both processes [27].
Atherosis and sclerosis have been shown to be epiphe-
nomena associated with aging, diabetes and hypertension.
In this study, AoAC grade was strongly associated with
higher age and lower BMI, indicating that the HD patients
with severe AoAC were malnourished. Although we could
not demonstrate any effects of hyperphosphatemia or ele-
vated calcium 9 phosphorus products on AoAC progres-
sion, the greater part of our results are in accordance with
findings from previous studies that examined the progres-
sion of vascular calcification in HD patients [28, 29].
Among the medications used in the subjects, anti-hyper-
tensive drugs or lipid-lowering drugs were not significantly
associated with the grade of AoAC. Concretely, medica-
tions such as angiotensin-converting enzyme inhibitors,
Heart Vessels (2012) 27:135142
angiotensin receptor blockers, calcium channel blockers,
and HMG-CoA inhibitors (statins) have recently been
shown to improve arterial stiffness as a result of lowering
blood pressure and vasodilatation. Unfortunately, we were
not able to detect the precise change by drug intervention
in this follow-up, because progressive change of calcium
deposition in the aortic arch is very slow. During the study
period, the dose pf phosphate binder was titrated every
month to achieve serum phosphorus and calcium concen-
trations in the target range ranges of 4.56.0 and
8.510.0 mg/dl, respectively. Therefore, it is likely that
there were no significant associations between AoAC grade
and serum levels of phosphorus and calcium.
There are several limitations in the present study.
Evaluation of AoAC is done using the semi-quantitative
method, because the method using four grades to evaluate
AoAC is relatively crude. Therefore, the true calcium
deposition in aortic wall may be underestimated. Second,
the largely observational design reduced the quality of the
study, and the population size in this study was also small.
Therefore, a largely prospective study using examinations
for both AoAC and abdominal aortic calcification is nec-
essary. Recently, Golestani et al. [30] have shown that
abdominal aortic calcification detected by dual X-ray
absorptiometry is a strong predictor for CV events. The
combination of these techniques seems to be useful for
future study.
In conclusion, the extent of AoAC and its significance
are generally easily disregarded in routine clinical work.
This study demonstrates that AoAC is an independent
predictor of increased risk of CV events. These findings
support our hypothesis that risk stratification by simple
assessment of AoAC using simple chest X-ray could play
an important role in primary preventive management of
atherosclerotic diseases in HD patients.
Acknowledgments This study was supported by a Grant-in-Aid
from the Japan Promotion Society for Cardiovascular Diseases.
Conflict of interest We have no conflict of interest to disclose.
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