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. 2025 Oct;35(10):6291-6301.
doi: 10.1007/s00330-025-11553-w. Epub 2025 Apr 2.

Visual ordinal grading of aortic valve calcification on routine non-gated chest CT predicts prognosis and alters management

Samuel G S Gunning  1 , John Graby  2   3 , Yashesh Mody  2 , Pia F P Charters  4 , Tim A Burnett  4 , David Murphy  2 , Ali Khavandi  2 , Jonathan C L Rodrigues  5   6
Affiliations

Visual ordinal grading of aortic valve calcification on routine non-gated chest CT predicts prognosis and alters management

Samuel G S Gunning et al. Eur Radiol. 2025 Oct.

Abstract

Objective: BSCI/BSTI guidelines recommend reporting aortic valve calcification (AVC) on all chest CTs regardless of indication. We assessed AVC frequency, severity, and association with aortic stenosis (AS) on echocardiography and its prognostic implications.

Methods: Retrospective, single-centre analysis of consecutive chest CTs (January-December 2015) for 200 patients per age group (< 40, 40-49, 50-59, 60-69, 70-79, 80-89, ≥ 90) performed for medical, surgical, and oncological indications. CTs were re-reviewed for the presence and graded severity of AVC and coronary artery calcification (CAC). Corresponding echocardiography reports (within 5 years) reviewed for AS. Comorbidities and clinical outcomes were recorded.

Results: One thousand three hundred seventy-seven patients were included (mean age 64 ± 20 years, 55% female). AVC was present in 25% (350/1377) and was more prevalent in males (p < 0.001). Frequency and severity increased with age (p < 0.001). 38% (524/1377) had an echocardiogram (median inter-test interval 4.3 months [IQR 0.4-17.5]). Sixteen per cent (29/178) with AVC had AS of any severity (8% [15/178] mild; 8% [14/178] moderate; 0% [0/178] severe). Sensitivity and specificity for AVC predicting AS were 91% and 70%, respectively. Extrapolating findings, 8% of individuals with AVC and without an echocardiogram may have undiagnosed AS. All-cause mortality occurred in 53% (734/1377), which AVC predicted independently of CAC and age (p < 0.001). Adjusting for confounders, severe AVC predicted all-cause mortality (HR 1.56 [1.10-2.22], p = 0.013).

Conclusions: AVC identified AS in 16% of patients. Additionally, severe AVC is an independent predictor of all-cause mortality in multivariable analysis. Validation in a prospective cohort is required to inform clinical practice guidelines.

Key points: Question New guidelines recommend reporting AVC on all non-gated chest CTs, the prognostic and clinical relevance of which is uncertain. Findings There are associations between visually quantified AVC, AS on echocardiography, and all-cause mortality in an unselected population referred for routine chest CT. Clinical relevance These results support the reporting of all severities of AVC, especially severe AVC, as a prognostic marker in all age groups. The clinical implications require further clarification in a prospective cohort.

Keywords: Aortic valve; Aortic valve stenosis; Echocardiography; Tomography; X-ray computed; calcification of.

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Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Dr J.C.L.R. Conflict of interest: The authors of this manuscript declare relationships with the following companies: J.C.L.R. reports a relationship with Aidence that includes: speaking and lecture fees. J.C.L.R. reports a relationship with Sanofi that includes: speaking and lecture fees. J.C.L.R. reports a relationship with NHS X that includes: consulting or advisory. J.C.L.R. reports a relationship with Heart and Lung Health that includes: employment. J.C.L.R. reports a relationship with Heart Flow that includes: physicians’ services. J.G. reports a relationship with Sanofi that includes: speaking and lecture fees. S.G.S.G. reports a relationship with Opto Health that includes: consulting or advisory. The remaining authors report no conflicts of interest. Statistics and biometry: No complex statistical methods were necessary for this paper. Informed consent: Written informed consent was not required as per the Health Research Authority’s decision tool. Ethical approval: Institutional Review Board approval was not required as per the Health Research Authority’s decision tool. This retrospective observational study included patients who had previously undergone clinically indicated imaging and was approved as a service evaluation by our institution’s Trust Audit Committee. Preliminary work was presented as an abstract at the 2023 British Cardiovascular Society Conference. Study subjects or cohorts overlap: No study subjects or cohorts have previously been reported. Methodology: Retrospective Observational Performed at one institution

Figures

Fig. 1
Fig. 1
Study flowchart, with patients excluded if there was absent or incomplete chest imaging or if there was CT evidence of prior aortic valve intervention
Fig. 2
Fig. 2
Frequency and severity (%) of AVC broken down by age group with percentages given
Fig. 3
Fig. 3
A Unadjusted survival curves for AVC severity and all-cause mortality. B Adjusted survival curves for AVC severity and all-cause mortality
Fig. 4
Fig. 4
Univariate analysis of all predictor variables for all-cause mortality
Fig. 5
Fig. 5
Multivariate analysis for all significant predictor variables for all-cause mortality
See this image and copyright information in PMC

References

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Supplementary concepts