Progressive increase in ascending aortic diameter across the menopausal transition: A longitudinal study using AI-based automated measurement from chest radiographs.

BACKGROUND: Despite the menopausal transition being a critical period of accelerating cardiovascular disease (CVD) risk, structural remodeling of the thoracic ascending aorta during this phase remains poorly characterized. MATERIALS AND METHODS: We analyzed 4427 Korean women who were premenopausal at baseline and underwent posteroanterior chest radiography. Maximum ascending aortic diameter was quantified using validated software based on deep learning. Menopausal stage was classified per STRAW+10 criteria. Linear mixed-effects models were used to examine longitudinal aortic changes across menopausal stages and effect modification among groups classified according to their PREVENT score for 10-year CVD risk. RESULTS: Mean age at baseline was 40.2 ± 3.9 years. Over a median follow-up of 7.3 years, age-adjusted maximum ascending aortic diameter increased across menopausal stages, from 2.901 cm in premenopause to 2.991 cm in postmenopause, remaining significant after multivariable adjustment. The association differed by PREVENT 10-year CVD risk (Pinteraction < 0.001). Among women in the lower three quartiles (quartiles 1-3, ≤0.8%), a significant increment was observed only in late transition (β = 0.035 cm; 95% CI 0.009, 0.061), whereas among those in the top quartile (quartile 4, >0.8%), the diameter showed progressive increases across all stages, with the largest increment in postmenopause (β = 0.094 cm; 95% CI 0.076, 0.112). CONCLUSION: Ascending aortic diameter showed progressive increases across the menopausal transition after adjustment for age and traditional CVD risk factors, with PREVENT-stratified differences. A significant increment even among women in the lower three quartiles during late transition suggests that stage-related differences in ascending aortic diameter may be detectable before menopause onset.