Abdominal CT Body Composition Thresholds Using Automated AI Tools for Predicting 10-year Adverse Outcomes

Abstract

Background CT-based body composition measures derived from fully automated artificial intelligence tools are promising for opportunistic screening. However, body composition thresholds associated with adverse clinical outcomes are lacking. Purpose To determine population and sex-specific thresholds for muscle, abdominal fat, and abdominal aortic calcium measures at abdominal CT for predicting risk of death, adverse cardiovascular events, and fragility fractures. Materials and Methods In this retrospective single-center study, fully automated algorithms for quantifying skeletal muscle (L3 level), abdominal fat (L3 level), and abdominal aortic calcium were applied to noncontrast abdominal CT scans from asymptomatic adults screened from 2004 to 2016. Longitudinal follow-up documented subsequent death, adverse cardiovascular events (myocardial infarction, cerebrovascular event, and heart failure), and fragility fractures. Receiver operating characteristic (ROC) curve analysis was performed to derive thresholds for body composition measures to achieve optimal ROC curve performance and high specificity (90%) for 10-year risks. Results A total of 9223 asymptomatic adults (mean age, 57 years ± 7 [SD]; 5152 women and 4071 men) were evaluated (median follow-up, 9 years). Muscle attenuation and aortic calcium had the highest diagnostic performance for predicting death, with areas under the ROC curve of 0.76 for men (95% CI: 0.72, 0.79) and 0.72 for women (95% CI: 0.69, 0.76) for muscle attenuation. Sex-specific thresholds were higher in men than women (P < .001 for muscle attenuation for all outcomes). The highest-performing markers for risk of death were muscle attenuation in men (31 HU; 71% sensitivity [164 of 232 patients]; 72% specificity [1114 of 1543 patients]) and aortic calcium in women (Agatston score, 167; 70% sensitivity [152 of 218 patients]; 70% specificity [1427 of 2034 patients]). Ninety-percent specificity thresholds for muscle attenuation for both risk of death and fragility fractures were 23 HU (men) and 13 HU (women). For aortic calcium and risk of death and adverse cardiovascular events, 90% specificity Agatston score thresholds were 1475 (men) and 735 (women). Conclusion Sex-specific thresholds for automated abdominal CT-based body composition measures can be used to predict risk of death, adverse cardiovascular events, and fragility fractures. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Ohliger in this issue.

Graphical abstract

Figure 1:

Flow diagram shows patient selection and exclusions. CTC = CT colonography, DICOM = Digital Imaging and Communications in Medicine.

Figure 2:

Body composition values in an 82-year-old man who underwent CT colonography for colon cancer screening in 2009 and died 1 year later. (A) Axial noncontrast CT image at the L3 level. (B) Axial noncontrast composite CT image at the L3 level shows the segmentation of visceral adipose tissue (gold), subcutaneous adipose tissue (blue), and muscle (red). (C) Coronal maximum intensity projection CT image shows quantification of aortic calcium (yellow). Patient body composition values: L3 muscle attenuation = 21 HU, aortic calcium Agatston score = 6586, and L3 visceral-to-subcutaneous adipose tissue ratio = 1.25.

Figure 3:

Abdominal aortic calcium in a 74-year-old woman who underwent CT colonography for colon cancer screening in 2008 and suffered a subsequent acute myocardial infarction 1 year later. (A) Axial noncontrast CT image at the L3 level. (B) Coronal maximum intensity projection CT image shows quantification of aortic calcium (yellow). The patient’s aortic calcium Agatston score was 4137, while the 90% specificity threshold aortic calcium Agatston score was 735.

Figure 4:

Body composition values in a 77-year-old woman who underwent CT colonography for colon cancer screening in 2007 and suffered a subsequent left subcapital femoral neck fracture 9 years later. (A) Axial noncontrast CT image at the L3 level. (B) Axial noncontrast composite CT image at the L3 level shows the segmentation of visceral adipose tissue (gold), subcutaneous adipose tissue (blue), and muscle (red). (C) Cross-table lateral radiograph shows a mildly displaced left subcapital femoral neck fracture (arrow). Body composition values: L3 muscle attenuation = 9 HU, aortic calcium Agatston score = 352, and L3 visceral-to-subcutaneous adipose tissue ratio = 0.80.

Figure 5:

Receiver operating characteristic (ROC) curves for deriving body composition thresholds. (A) Male muscle attenuation for prediction of 10-year risk of death. (B) Female muscle attenuation for prediction of 10-year risk of death. (C) Male abdominal aortic calcium for prediction of 10-year risk of death. (D) Female abdominal aortic calcium for prediction of 10-year risk of death. Optimal Youden index thresholds are denoted by the squares, and high-specificity (defined as 90% specificity) thresholds are denoted by the circles. AUC = area under the ROC curve.