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We assessed the association between TAC on chest radiographs and major adverse limb events (MALE), other cardiovascular outcomes, and mortality in cardiovascular disease patients. A total of 4680 patients were included from the prospective Utrecht Cardiovascular Cohort-Second Manifestation of ARTerial disease cohort. TAC severity was classified based on chest radiographs by certified readers as mild, moderate, and severe. Multivariate cox proportional hazard models were utilized to assess associations between TAC and incident MALE defined as major amputation, peripheral revascularization or thrombolysis in the lower limb. Secondary endpoints included major adverse cardiovascular events (MACE: stroke, myocardial infarction, and vascular death), and all-cause mortality. A total of 4680 patients were included. TAC was present in 1789 (38%) patients. After a median follow-up of 11.8 years (interquartile range: 7.6\u201315.7 years), 426 MALE, 992 MACE, and 1387 deaths occurred. TAC presence was associated with incident MALE after adjustments, (hazard ratio (HR):2.14;95%CI:1.73\u20132.65) and this risk increased with TAC severity (HR\n                    <jats:sub>mild<\/jats:sub>\n                    : 1.97; 95%CI:1.51\u20132.57, HR\n                    <jats:sub>moderate<\/jats:sub>\n                    : 2.04; 95%CI:1.56\u20132.68, and HR\n                    <jats:sub>severe<\/jats:sub>\n                    : 2.71; 95%CI: 2.02\u20133.65). Moreover, TAC was associated with incident MACE (HR:1.22;95%CI:1.06\u20131.40), ischemic stroke (HR: 1.45; 95%CI: 1.11\u20131.91), and vascular death (HR: 1.35; 95%CI: 1.13\u20131.63). TAC was only associated with all-cause mortality (HR:1.34;95%CI:1.18\u20131.52) in patients who experienced a previous cardiovascular event. In cardiovascular disease patients, TAC on chest radiographs is associated with an increased risk for incident MALE. In addition, we found that TAC was associated with incident ischemic stroke, MACE and all-cause mortality.\n                  <\/jats:p>","DOI":"10.1007\/s10554-025-03435-5","type":"journal-article","created":{"date-parts":[[2025,6,2]],"date-time":"2025-06-02T12:44:55Z","timestamp":1748868295000},"page":"1437-1444","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Thoracic aortic calcifications on chest radiographs and incident major adverse limb events in cardiovascular disease patients"],"prefix":"10.1007","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8196-3949","authenticated-orcid":false,"given":"Netanja I.","family":"Harlianto","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Firdaus A.A.","family":"Mohamed Hoesein","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Willem P.T.H.","family":"Mali","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marjolein E.","family":"Hol","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Constantijn E.V.B.","family":"Hazenberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joost A.","family":"van Herwaarden","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wouter","family":"Foppen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pim A.","family":"de Jong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"UCC-SMART-Studygroup","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,6,2]]},"reference":[{"key":"3435_CR1","doi-asserted-by":"publisher","first-page":"234","DOI":"10.1159\/000096744","volume":"44","author":"RH Mackey","year":"2007","unstructured":"Mackey RH, Venkitachalam L, Sutton-Tyrrell K (2007) Calcifications, arterial stiffness and atherosclerosis. 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