Michael Blaha

Objective The effectiveness of coronary artery calcification (CAC) for risk stratification in obesity, in which imaging is often limited because of a reduced signal to noise ratio, has not been well studied. Methods Data from 9334 participants (mean age: 53.3 ± 9.7 years; 67.9% men) with BMI ≥ 30 kg/m 2 from the CAC Consortium, a retrospectively assembled cohort of individuals with no prior cardiovascular diseases (CVD), were used. The predictive value of CAC for all‐cause and cause‐specific mortality was evaluated using multivariable‐adjusted Cox proportional hazards and competing‐risks regression. Results Mean BMI was 34.5 (SD 4.4) kg/m 2 (22.7% Class II and 10.8% Class III obesity), and 5461 (58.5%) had CAC. Compared with CAC = 0, those with CAC = 1–99, 100–299, and ≥300 Agatston units had higher rates (per 1000 person‐years) of all‐cause (1.97 vs. 3.5 vs. 5.2 vs. 11.3), CVD (0.4 vs. 1.1 vs. 1.5 vs. 4.2), and coronary heart disease (CHD) mortality (0.2 vs. 0.6 vs. 0.6 vs. 2.5), respectively, after mean follow‐up of 10.8 ± 3.0 years. After adjusting for traditional cardiovascular risk factors, CAC ≥ 300 was associated with significantly higher risk of all‐cause (hazard ratio [HR]: 2.05; 95% CI: 1.49–2.82), CVD (subdistribution HR: 3.48; 95% CI: 1.81–6.70), and CHD mortality (subdistribution HR: 5.44; 95% CI: 2.02–14.66), compared with CAC = 0. When restricting the sample to individuals with BMI ≥ 35 kg/m 2 , CAC ≥ 300 remained significantly associated with the highest risk. Conclusions Among individuals with obesity, including moderate–severe obesity, CAC strongly predicts all‐cause, CVD, and CHD mortality and may serve as an effective cardiovascular risk stratification tool to prioritize the allocation of therapies for weight management.