Background and Purpose: Aortic calcification is a major risk factor for cardiovascular disease (CVD) related deaths. We investigated the relation between mortality and aspects of number, size, morphology and distribution of calcified plaques in the lumbar aorta of postmenopausal women. Methods: 308 women aged 48 to 76 were followed for 8.3+-0.3 years and cardiovascular, cancer and all-cause deaths were recorded. Several aortic calcification markers were quantified: number, morphology, distribution, from outlines of the calcified plaques in lumbar X-rays at baseline. These markers were compared to SCORE card, Framingham score, and the Aortic Calcification Severity score - AC24. Results: AC24 adjusted by age, waist circumference, and triglyceride levels predicted mortality in postmenopausal women (CVD p=0.03, All-cause p=0.006). The SCORE card and the Framingham score resulted in mortality odds ratios (OR) of 5.0 and 5.2 - defining high risk as >=6 and >=18, respectively. All scores based on the calcification geometry provided highly significant predictions. The number of calcified deposits (NCD) was a significant predictor even after
adjustment by the AC24 score (p=0.002). The AC24 score adjusted by NCD had no predictive value (p=0.53). The high risk patients (NCD >= 13) had mortality OR 12. The morphological atherosclerosis calcification distribution (MACD) index provided OR 20 which was significantly higher than AC24 and any single or multivariate metabolic/physical marker. Conclusions: The newly established MACD-index provides a unique combination of morphology and distribution
of aortic calcifications, factors that in a combination increase the biological relevance of the index by emphasizing that smaller plaques with a spread elongated morphology have a larger growth potential and thereby subsequent rupture potential. Thereby, in the current cohort with a long term follow-up the MACD-index is a convincingly strong predictor of CVD mortality, with an odds ratio of 20, of postmenopausal death related to CVD events.