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. 2017 Sep 8;12(9):e0182952.
doi: 10.1371/journal.pone.0182952. eCollection 2017.

Lower limb arterial calcification (LLAC) scores in patients with symptomatic peripheral arterial disease are associated with increased cardiac mortality and morbidity

Mohammed M Chowdhury  1 , Gregory C Makris  2 , Jason M Tarkin  3 , Francis R Joshi  4 , Paul D Hayes  1 , James H F Rudd  3 , Patrick A Coughlin  1
Affiliations

Lower limb arterial calcification (LLAC) scores in patients with symptomatic peripheral arterial disease are associated with increased cardiac mortality and morbidity

Mohammed M Chowdhury et al. PLoS One. .

Abstract

Aims: The association of coronary arterial calcification with cardiovascular morbidity and mortality is well-recognized. Lower limb arterial calcification (LLAC) is common in PAD but its impact on subsequent health is poorly described. We aimed to determine the association between a LLAC score and subsequent cardiovascular events in patients with symptomatic peripheral arterial disease (PAD).

Methods: LLAC scoring, and the established Bollinger score, were derived from a database of unenhanced CT scans, from patients presenting with symptomatic PAD. We determined the association between these scores outcomes. The primary outcome was combined cardiac mortality and morbidity (CM/M) with a secondary outcome of all-cause mortality.

Results: 220 patients (66% male; median age 69 years) were included with follow-up for a median 46 [IQR 31-64] months. Median total LLAC scores were higher in those patients suffering a primary outcome (6831 vs. 1652; p = 0.012). Diabetes mellitus (p = 0.039), ischaemic heart disease (p = 0.028), chronic kidney disease (p = 0.026) and all-cause mortality (p = 0.012) were more common in patients in the highest quartile of LLAC scores. The area under the curve of the receiver operator curve for the LLAC score was greater (0.929: 95% CI [0.884-0.974]) than for the Bollinger score (0.824: 95% CI [0.758-0.890]) for the primary outcome. A LLAC score ≥ 4400 had the best diagnostic accuracy to determine the outcome measure.

Conclusion: This is the largest study to investigate links between lower limb arterial calcification and cardiovascular events in symptomatic PAD. We describe a straightforward, reproducible, CT-derived measure of calcification-the LLAC score.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Arterial calcification.
Unenhanced multi-sliced computed tomography images of arterial calcification (A) circumferential calcification of the distal abdominal aorta (B) calcification of both distal superficial femoral arteries at the level of the adductor hiatus with evidence of significant intraluminal stenotic plaque disease. Arrows identify areas of calcification.
Fig 2
Fig 2. Study profile.
Fig 3
Fig 3. Correlation between total LLAC and Bollinger scores in patients with symptomatic peripheral arterial disease.
Statistical analysis performed using Spearman’s rank correlation coefficient. p<0.05 taken to be statistically significant.
Fig 4
Fig 4. Receiver-operator curves for total LLAC and Bollinger scores and the primary outcome of cardiac mortality and morbidity.
AUC for the LLAC score was 0.929 (95% CI 0.884–0.974), p< 0.001 AUC for the Bollinger score 0.824 (95% CI 0.758–0.890), p<0.001 ROC = receiver-operator curve; LLAC = lower limb arterial calcification; AUC = area under the curve; CI = confidence interval.
See this image and copyright information in PMC

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