The ASAP study: association of atherosclerosis with pathobiology in a caucasian cohort—a study of 3400 autopsy reports
According to the World Health Organization (WHO), cardiovascular disease is the leading cause of death globally, accounting for 17.9 million deaths per year . Atherosclerosis is a chronic disease that affects the wall of arteries causing plaques to grow that may eventually impede blood flow , . Autopsy studies of subjects who died of unnatural deaths, such as suicides, homicides or accidents provide a special chance to study atherosclerosis in several aspects – . Despite being a significant contributor to morbidity and mortality, our understanding of atherosclerosis, particularly its characteristics and progression—such as identifying the initial site and the rate of deterioration—in the Central European database, remains limited . While data exist for various racial groups, there is a lack of information specifically for Caucasian subjects. To address these knowledge gaps, our study aimed to conduct a cross-sectional study in a great Central European cohort, encompassing over 3000 case reports. Our primary aim was to identify the initial site of atherosclerosis within the cardiovascular system in healthy subjects and to observe relationships between risk factors, such as age, sex, body mass index (BMI) and thickness of the abdominal tissue and their associations with atherosclerosis. Our goal was to facilitate the development of a personalized therapeutic approach based on our findings. Methods.   Data of 3400 subjects from 1928 until 2010, aged 0─96 years from forensic autopsy reports of the Forensic Medicine Institute (Albert Szent-Györgyi Health Center, University of Szeged, Szeged, Hungary) have been enrolled for this study. Data gathering lasted from 2016 until 2020. All subjects were Caucasian, and deaths occurred in Southern Great Plain, Hungary (Csongrád-Csanád-, Bács-Kiskun- and Békés-counties). Inclusion criteria were unnatural deaths: accident, homicide and suicide. These cases were selected because the subjects were not suffering from any terminal illnesses at the time of their deaths. Additionally, the deaths were caused by external factors. Therefore, examining the vascular system of these individuals is akin to studying that of a healthy person, provided the lethal event did not occur. Exclusion criteria included the suspected or confirmed natural deaths and incomplete data. The first 50 cases from each year were recruited, however, in some years there have been fewer cases than our goal. Anthropometry Anthropometric data (age, sex, body weight, height) were collected from the reports. The subjects were categorised by their BMI into normal weight (N, BMI < 25 kg/m2) and overweight (OW, BMI ≥ 25 kg/m2) groups. Morphological parameters Morphological parameters were collected from the reports. Autopsies were performed at the same institution following a standard operating procedure for each case. Therefore, the assessment and classification of vascular lesions can be considered uniform. According to the autopsy reports, this research specifically concentrated on the assessment of atherosclerotic degeneration in six arterial regions. These regions included the ascending aorta, thoracic aorta, abdominal aorta, carotid arteries, coronary arteries, and cerebral arteries. The selection of these segments was based on their consistent availability in the autopsy reports, as well as their known clinical significance in predicting cardiovascular events. While we acknowledge the importance of other arterial regions, detailed data for these were not available within the scope of the forensic medicine protocol, which does not typically include a more comprehensive cardiovascular system analysis. To receive a correct classification of the atherosclerotic lesions, five categories were created (atherosclerosis score, AS) based on the macroscopic description of the autopsy report. Zero is for smooth and glowing reflective endothelium (AS 0), one is for fatty streak (AS 1), two is for plaques without macroscopic calcification (AS 2), three is for plaques with macroscopic calcification (AS 3) and four is for ulcerated calcified plaques (AS 4). Since this is a retrospective study and encompasses a large period (1928─2010), merely the precise written characteristic of the endothelial layer was available in each case, without any special characteristic of the lesions (e.g. histopathological examination, risk factors). In other words, data were collected directly from the written autopsy reports, and based on the detailed description each arterial region was assigned with an AS score. Abdominal fat tissue was quantified by measuring its thickness using a measuring tape following the opening of the abdominal wall. Local manifestation of atherosclerosis For the determination of the first onset of atherosclerosis in the investigated six regions, only those cases have been included, where at least two AS were available from different regions.   Anthropometric data (age, sex, body weight, height) were collected from the reports. The subjects were categorised by their BMI into normal weight (N, BMI < 25 kg/m2) and overweight (OW, BMI ≥ 25 kg/m2) groups.   Morphological parameters were collected from the reports. Autopsies were performed at the same institution following a standard operating procedure for each case. Therefore, the assessment and classification of vascular lesions can be considered uniform. According to the autopsy reports, this research specifically concentrated on the assessment of atherosclerotic degeneration in six arterial regions. These regions included the ascending aorta, thoracic aorta, abdominal aorta, carotid arteries, coronary arteries, and cerebral arteries. The selection of these segments was based on their consistent availability in the autopsy reports, as well as their known clinical significance in predicting cardiovascular events. While we acknowledge the importance of other arterial regions, detailed data for these were not available within the scope of the forensic medicine protocol, which does not typically include a more comprehensive cardiovascular system analysis. To receive a correct classification of the atherosclerotic lesions, five categories were created (atherosclerosis score, AS) based on the macroscopic description of the autopsy report. Zero is for smooth and glowing reflective endothelium (AS 0), one is for fatty streak (AS 1), two is for plaques without macroscopic calcification (AS 2), three is for plaques with macroscopic calcification (AS 3) and four is for ulcerated calcified plaques (AS 4). Since this is a retrospective study and encompasses a large period (1928─2010), merely the precise written characteristic of the endothelial layer was available in each case, without any special characteristic of the lesions (e.g. histopathological examination, risk factors). In other words, data were collected directly from the written autopsy reports, and based on the detailed description each arterial region was assigned with an AS score. Abdominal fat tissue was quantified by measuring its thickness using a measuring tape following the opening of the abdominal wall.   For the determination of the first onset of atherosclerosis in the investigated six regions, only those cases have been included, where at least two AS were available from different regions.   The correlation of non-linearly related Year and variables was tested using Spearman’s method. The shape of the relationship was captured using locally estimated scatterplot smoothing (LOESS). LOESS functions were also used to plot the relationship between Year and BMI and Year and different AS prevalence. To investigate the variables influencing the manifestation of AS at different levels, we employed ordinal logistic regression analysis (OLS). Our dependent variable was the level of AS manifestation, categorized into ordered levels. The independent variables included in the model were Sex, Age, Abdominal thickness, and Overweight status. Sex was coded as 0 for males and 1 for females. Overweight status was dichotomized, with 0 representing normal weight (N) and 1 indicating overweight or having a BMI over 25 kg/m 2 (OW). We assessed the model fit using the P value of the likelihood ratio test and McFadden’s Pseudo R 2 . McFadden’s Pseudo R 2 , a measure of model fit, showed the proportion of variance explained by the model. The significance of the variables was determined using Wald test p-values. Interaction terms were included for Age and Overweight status, and Age and Sex, to explore whether the relationship between these variables and AS manifestation level varied depending on the level of another variable. The odds ratios derived from the regression coefficients provided a measure of the change in odds of higher AS manifestation levels associated with a one-unit change in the predictor variable, holding all other variables constant. Continuous variables were standardized to allow for a comparison of the relative importance of each predictor in the model, reflected by the standardized coefficients (beta values). Values of P < 0.05 were considered significant. Data analysis was performed using RStudio (2023.12.1 + 402) with the following packages: car , MASS , ggpubr , ggplot2 , cowplot , dplyr .   Epidemiology Detailed characteristics of the data are presented in the Supplementary Table 1. Body mass index and atherosclerosis score Across the whole database, the earliest recorded BMI data was obtained in the year 1931 with a BMI of 22.82 kg/m 2 . Temporal analysis of the data set revealed that the average BMI was at its lowest in 1947 (BMI = 18.43 kg/m 2 ) and reached its highest peak in 2005 (BMI = 27.88 kg/m 2 ). Body mass index and atherosclerosis score in the 50-year-old subpopulation Since there is a non-linear multicollinear connection between BMI, year and age, we needed to keep the age constant at 50 years to study how BMI changes over time. This decision was made to simplify interpretation while ensuring statistical robustness, as 50-year-olds had the highest number of data points. Preliminary analyses with other age groups, such as 30-year-olds, showed that trends remained consistent across calendar years, supporting the validity of our approach. As a representative subgroup, we observed a slightly curved and statistically significant relationship in the BMI of individuals aged 50 between 1931 and 2010, as shown in Fig. a using Spearman’s correlation analysis. To facilitate comparison, the red bars on both graphs represent the same time. Interestingly, even though the BMI of 50-year-olds showed a decreasing trend during this period, Fig. b demonstrates that their average AS increased over the same timeframe. Examination of the AS data revealed that from 1934 until 1940 AS zero and two were the most prevalent among the population. Beginning in 1940 and reaching a peak in 1954, the prevalence of AS two gradually increased, and then declined again until the 1980s. From 1966 and peaking in 1980, AS three became the most frequent AS. After 2000 the prevalence of AS 2 surpasses the prevalence of AS 3 again, showing a noticeable increment until 2010. AS four and one have been observed with a consistent probability throughout the years studied.   Detailed characteristics of the data are presented in the Supplementary Table 1.   Across the whole database, the earliest recorded BMI data was obtained in the year 1931 with a BMI of 22.82 kg/m 2 . Temporal analysis of the data set revealed that the average BMI was at its lowest in 1947 (BMI = 18.43 kg/m 2 ) and reached its highest peak in 2005 (BMI = 27.88 kg/m 2 ).   Since there is a non-linear multicollinear connection between BMI, year and age, we needed to keep the age constant at 50 years to study how BMI changes over time. This decision was made to simplify interpretation while ensuring statistical robustness, as 50-year-olds had the highest number of data points. Preliminary analyses with other age groups, such as 30-year-olds, showed that trends remained consistent across calendar years, supporting the validity of our approach. As a representative subgroup, we observed a slightly curved and statistically significant relationship in the BMI of individuals aged 50 between 1931 and 2010, as shown in Fig. a using Spearman’s correlation analysis. To facilitate comparison, the red bars on both graphs represent the same time. Interestingly, even though the BMI of 50-year-olds showed a decreasing trend during this period, Fig. b demonstrates that their average AS increased over the same timeframe. Examination of the AS data revealed that from 1934 until 1940 AS zero and two were the most prevalent among the population. Beginning in 1940 and reaching a peak in 1954, the prevalence of AS two gradually increased, and then declined again until the 1980s. From 1966 and peaking in 1980, AS three became the most frequent AS. After 2000 the prevalence of AS 2 surpasses the prevalence of AS 3 again, showing a noticeable increment until 2010. AS four and one have been observed with a consistent probability throughout the years studied.   A total of 3289 individuals were included in the dataset for which an AS could be calculated. Of this cohort, 51.7% ( n = 1735) were male and 48.3% ( n = 1554) were female. Local manifestation In Fig. the reduction of the blue colour and the increment of warm colours show the prevalence of different AS scores, subsequently representing the extent of atherosclerosis in the investigated areas, in males and females. The most pronounced decline in the light blue colour represents that atherosclerotic degeneration progresses most rapidly in the following order: abdominal aorta, thoracic aorta, coronary arteries, carotid arteries, ascending aorta, and finally, cerebral arteries. The main observation from Fig. is that atherosclerosis commences as early as the first and second decade of life in each area except in the cerebral arteries in both sexes. In the abdominal aorta AS one is present in 90% of male subjects at the age of 64, AS two at the age of 76, AS three at the age of 78 and AS four at the age of 88. Among females AS one is present at the age of 62, AS two at the age 78 years, AS three at the age of 84 and AS four at the age of 88. Time course of atherosclerosis The results from the Kaplan-Meier analyses (Table ) reveal that men experience statistically faster deterioration in all blood vessels compared to women in this study ( p < 0.005). The most rapid deterioration in both sexes was in the abdominal aorta. The most significant disparity in atherosclerotic progression between males and females was noted in the coronary and carotid arteries, with atherosclerosis manifesting a decade earlier in males than in females in both of these regions. In men, 50% of the sample population had AS greater than one in the coronary arteries and carotid arteries before the age of 58, whereas in women this rate was only measured at the age of 68. Effects of different variables on manifestation To uncover which variables most significantly impact the manifestation at different AS levels, we applied ordinal logistic regression. The model fit with the utilized variables (Sex, Age, Abdominal thickness, Overweight) was found to be significant ( p < 0.001), alongside a McFadden Pseudo R 2 of 0.41. Upon examining the variables individually, Age’s main effect was significant ( p < 0.001), indicating that with each unit increase in Age, the odds of higher AS manifestation increase by 505%. Similarly, being overweight increases the likelihood of higher AS manifestation by 33% ( p = 0.009). However, it’s noteworthy to mention the significant interaction between Age and overweight ( p = 0.002), suggesting that individuals’ overweight status acts as a predisposing factor approximately up to the age of 55 (Fig. a), after which Age moderates the effect of overweight. A similar moderating effect of Age is observed concerning Sex (Fig. b). Sex itself proved to be a significant predictor, with males having a 35% higher chance of higher AS than females ( p = 0.001). However, the significant interaction with Age ( p = 0.041) exerts a moderating influence: the difference between genders becomes defined around the age of 25 and, similar to the effect of overweight, balances out around the age of 55. This occurs despite the abdominal fat thickness and the likelihood of being overweight changing in a similar trend with advancing age among both women and men. The main effect of Abdominal thickness was also significant ( p = 0.005), where each unit increase in Abdominal thickness increases the odds of higher AS by 12% (Fig. c). Although binomial variables inherently cannot undergo standardization, standardizing the continuous variables allowed for an assessment of the relative importance of variables, which in decreasing order of importance are: Age (β = 1.801), Sex (β = -0.302), Overweight (β = 0.285), and Abdominal thickness (β = 0.117).   In Fig. the reduction of the blue colour and the increment of warm colours show the prevalence of different AS scores, subsequently representing the extent of atherosclerosis in the investigated areas, in males and females. The most pronounced decline in the light blue colour represents that atherosclerotic degeneration progresses most rapidly in the following order: abdominal aorta, thoracic aorta, coronary arteries, carotid arteries, ascending aorta, and finally, cerebral arteries. The main observation from Fig. is that atherosclerosis commences as early as the first and second decade of life in each area except in the cerebral arteries in both sexes. In the abdominal aorta AS one is present in 90% of male subjects at the age of 64, AS two at the age of 76, AS three at the age of 78 and AS four at the age of 88. Among females AS one is present at the age of 62, AS two at the age 78 years, AS three at the age of 84 and AS four at the age of 88.   The results from the Kaplan-Meier analyses (Table ) reveal that men experience statistically faster deterioration in all blood vessels compared to women in this study ( p < 0.005). The most rapid deterioration in both sexes was in the abdominal aorta. The most significant disparity in atherosclerotic progression between males and females was noted in the coronary and carotid arteries, with atherosclerosis manifesting a decade earlier in males than in females in both of these regions. In men, 50% of the sample population had AS greater than one in the coronary arteries and carotid arteries before the age of 58, whereas in women this rate was only measured at the age of 68.   To uncover which variables most significantly impact the manifestation at different AS levels, we applied ordinal logistic regression. The model fit with the utilized variables (Sex, Age, Abdominal thickness, Overweight) was found to be significant ( p < 0.001), alongside a McFadden Pseudo R 2 of 0.41. Upon examining the variables individually, Age’s main effect was significant ( p < 0.001), indicating that with each unit increase in Age, the odds of higher AS manifestation increase by 505%. Similarly, being overweight increases the likelihood of higher AS manifestation by 33% ( p = 0.009). However, it’s noteworthy to mention the significant interaction between Age and overweight ( p = 0.002), suggesting that individuals’ overweight status acts as a predisposing factor approximately up to the age of 55 (Fig. a), after which Age moderates the effect of overweight. A similar moderating effect of Age is observed concerning Sex (Fig. b). Sex itself proved to be a significant predictor, with males having a 35% higher chance of higher AS than females ( p = 0.001). However, the significant interaction with Age ( p = 0.041) exerts a moderating influence: the difference between genders becomes defined around the age of 25 and, similar to the effect of overweight, balances out around the age of 55. This occurs despite the abdominal fat thickness and the likelihood of being overweight changing in a similar trend with advancing age among both women and men. The main effect of Abdominal thickness was also significant ( p = 0.005), where each unit increase in Abdominal thickness increases the odds of higher AS by 12% (Fig. c). Although binomial variables inherently cannot undergo standardization, standardizing the continuous variables allowed for an assessment of the relative importance of variables, which in decreasing order of importance are: Age (β = 1.801), Sex (β = -0.302), Overweight (β = 0.285), and Abdominal thickness (β = 0.117).   This is the first and largest autopsy-based research covering almost a century, regarding atherosclerosis in Central European subjects so far. In 1953, Enos and his co-workers published unexpected results about advanced lesions in coronary arteries among young US soldiers killed in action in Korea . This landmark article led to the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Study, which declares that early stages of atherosclerosis can be detected as early as teenage years . Similar to the PDAY study a number of research groups conducted not only autopsy-based, but longitudinal, community-based studies focusing on the epidemiology, morphology and risk factors of atherosclerosis . Despite these numerous studies, the exact course of atherosclerosis remained unclear , since the development of atherosclerosis in human populations may change very much in the course of the life of one generation. This inspired our research group to create a new database in association with atherosclerosis in which data from a Central European cohort are reported. Body mass index and atherosclerosis score in the 50-year-old subpopulation Although the data on BMI are subject to a variety of interpretations, these results represent most precisely the historical aspects of this study. As a representative subpopulation of the cohort, we analysed the most sensitive age group regarding BMI. While we focused on 50-year-olds to ensure sufficient data points for statistical analysis, preliminary exploration of other age groups, such as 30-year-olds, showed similar trends in AS over time. This suggests that the patterns observed are not strictly age-dependent but are influenced by broader generational and period effects. Certainly, the lowest point in this graph (Fig. a) is seen after World War II, in 1947. The increment that follows this period might result from the following economic expansion. However, prenatal factors caused by World War II (WW II) also have a significant impact on BMI. First, Ravelli reported that the progeny of survivors of WW II presented a higher prevalence of obesity and diabetes . Later further researchers found that the prevalence of obesity might be expected to be higher in patients who are exposed to malnutrition during gestation or early childhood , . Furthermore, individuals with lower birth weight caused by suboptimal maternal nutrition, seemed to be associated with increased upper visceral adiposity and its harmful consequences such as increased risk of cardiovascular , . Presumably, these above mentioned effects simultaneously appear in the highest peak of the BMI curve 58 years later after the deepest point. Surprisingly in Fig. b the AS curve does not precisely follow the BMI during the investigated period. Approximately from 1930 to 1970 AS 0 seems to have “disappeared” in the 50-year-old population in this dataset. However, this category merely transforms to more severe stages of atherosclerosis. These subjects on the figure with AS zero were born between 1880 and 1910, during a relatively ideal period regarding life circumstances in association with atherosclerosis. This era was characterized by a predominantly agrarian society, where individuals engaged in physically demanding agricultural labor and had limited access to processed foods, resulting in lower rates of obesity and diet-related diseases. Moreover, the healthier lifestyle of 1890─1910 also benefited from reduced exposure to environmental pollutants and a more physically active daily routine, contributing to lower incidences of chronic respiratory ailments and cardiovascular conditions compared to modern sedentary lifestyles. The reduction of AS zero after 1940, or in other words the transformation of AS zero to higher AS, supports the implication of atherosclerosis as an actual civilization disease, caused the offset by different factors such as healthy metabolism, active lifestyle, more favourable body mass, lean diet, low blood lipids and cardiorespiratory health . Furthermore, famine not only impacts BMI but blood pressure. Consequently, subjects with higher AS might be the descendants of the mothers malnourished during WW II . As the prevalence of AS zero decreases and shifts towards higher AS categories, the curves for AS two and three rise. Similarly, around the mid-1960s, AS zero and two categories transition to AS three—marking the first crossover point. This correlation suggests that coronary heart disease mortality peaked in the 1960s. Since then, clinical manifestations of atherosclerosis have become the most frequent cause of death and one of the leading sources of morbidity, disability, and hospitalization today . The second cross (around 2005─2010) of the curves AS two and three shows the improvement in fighting the conditions causing atherosclerosis. This finding represents, that the more effective treatment methods have made a noticeable impact on the cardiovascular state. The development of commercial statins is a cornerstone in atherosclerotic management. In September 1987, lovastatin was given FDA approval to become the first commercial statin , . Statins have undergone extensive evaluation through numerous large-scale clinical trials, which encompassed a total of 90,000 participants who were observed over 5 years – . In all of these investigations, the outcomes consistently demonstrated that statin therapy reduces plasma LDL levels by 25–35% and diminishes the occurrence of heart attacks by 25–30%. Moreover, increased awareness has been accomplished, promoting a healthy lifestyle. Lack of smoking, BMI between 18.5 and 24.9, regular physical activity, moderate alcohol intake and healthy diet at mid-life is associated with a longer life expectancy free of major chronic diseases . The combination of these factors has led to a marked decrease in the AS three category. The marked increase in AS from the 1960s onward aligns with a shift in lifestyle, including the rise of processed foods and a more sedentary way of life, while the decrease observed after 2005 reflects the success of medical interventions, particularly the widespread use of statins and enhanced cardiovascular risk management. The most severe category, AS 4, exhibits minimal prevalence compared to the other scores. Our research group posits that this is due to subjects with ulcerated plaques potentially dying from cardiovascular causes, thereby being absent from this database. This finding bolsters the argument that our dataset is representative of the general healthy population. Local manifestation, sex differences in atherosclerosis score and age of onset. Local manifestation An exciting aspect of the pathophysiology of atherosclerosis is the observation that arterial lesions show a non-random pattern in their development based on animal and human models, which correlates strongly with the arterial branch points and other regions of altered haemodynamics . In 1965, Mitchell and Schwartz found the appearance of lipid staining in the descending thoracic aorta based on autopsy studies , later in 1971, Caro and his co-workers pointed out the increased prevalence of fatty streaks in the initial segment abdominal aorta, caused by the increased inflow tract of the large branches . Similar distributions of atherosclerosis were established by subsequent research; however, none of them investigated six different regions in the same subjects – . Our findings help to clarify that atherosclerotic lesions occur first in the abdominal aorta, followed by the thoracic aorta, the ascending aorta, the carotid artery, coronary arteries, and finally the cerebral arteries. Time course of atherosclerosis Our study reports a much wider range of age (0─96 years) compared to the PDAY study (15─34 years), Bogalusa Heart Study (4─51 years), Muscatine Study (8─37 years) or Young Finns Study (8─45 years) , – . Nevertheless, it is worth noting that the PDAY study provides longitudinal data solely on the prevalence of different stages of atherosclerosis, but only within three vascular regions: the abdominal and thoracic aorta, and the right coronary artery. The broader age range and inclusion of three additional arterial regions (ascending aorta, cerebral arteries, and carotid arteries) enable us to construct a more precise understanding of the initiation of atherosclerosis in specific anatomical locations and explore potential gender disparities. Figure illustrates that atherosclerotic lesions appear already in the first decade of the lifetime in the abdominal aorta. This discovery regarding the early onset of atherosclerosis aligns with the primary findings of the PDAY study . Moreover it can be seen in Fig. b, that - similarly to all the other regions - in men this phenomenon appears earlier, which might stem from the female cardiovascular benefits caused by the ovarian sex steroid hormones until menopause . Around 55 years female subjects gain upon male subjects in our research. The manifestation of atherosclerosis in the investigated regions varies by around six and ten years between men and women, the lowest difference is presented in the abdominal aorta and cerebral arteries (six years), and the greatest difference is in the coronary arteries and in the carotid arteries (ten years) (Table ). Consequently, based on our observations, the peak prevalence of coronary heart disease in women is expected to occur approximately 6 to 10 years later than in men, a phenomenon supported by relevant literature . Effects of overweight on the manifestation Our research indicates that vascular aging may commence earlier in overweight individuals compared to their normal-weight counterparts in both sexes (Fig. a). Overweight and obesity are well-established risk factors for cardiovascular morbidity and mortality . However, age modifies this effect, and the two lines converge at around age 55. After this age range, the protective effect of normal weight might be lost and age can be considered as a risk factor in the same way as being overweight before the age of 55. In concordance with our previous result, Fig. b illustrates that males are more vulnerable to atherosclerosis until their mid-50s, at which point females become similarly affected by vascular ageing. These results indicate that risk stratification solely based on BMI is inadequate, as a normal-weight patient over 55 years of age faces a similar risk of atherosclerosis as their overweight counterpart. It will be crucial in the future to develop multifactorial risk assessment systems that enable personalized evaluations.   Although the data on BMI are subject to a variety of interpretations, these results represent most precisely the historical aspects of this study. As a representative subpopulation of the cohort, we analysed the most sensitive age group regarding BMI. While we focused on 50-year-olds to ensure sufficient data points for statistical analysis, preliminary exploration of other age groups, such as 30-year-olds, showed similar trends in AS over time. This suggests that the patterns observed are not strictly age-dependent but are influenced by broader generational and period effects. Certainly, the lowest point in this graph (Fig. a) is seen after World War II, in 1947. The increment that follows this period might result from the following economic expansion. However, prenatal factors caused by World War II (WW II) also have a significant impact on BMI. First, Ravelli reported that the progeny of survivors of WW II presented a higher prevalence of obesity and diabetes . Later further researchers found that the prevalence of obesity might be expected to be higher in patients who are exposed to malnutrition during gestation or early childhood , . Furthermore, individuals with lower birth weight caused by suboptimal maternal nutrition, seemed to be associated with increased upper visceral adiposity and its harmful consequences such as increased risk of cardiovascular , . Presumably, these above mentioned effects simultaneously appear in the highest peak of the BMI curve 58 years later after the deepest point. Surprisingly in Fig. b the AS curve does not precisely follow the BMI during the investigated period. Approximately from 1930 to 1970 AS 0 seems to have “disappeared” in the 50-year-old population in this dataset. However, this category merely transforms to more severe stages of atherosclerosis. These subjects on the figure with AS zero were born between 1880 and 1910, during a relatively ideal period regarding life circumstances in association with atherosclerosis. This era was characterized by a predominantly agrarian society, where individuals engaged in physically demanding agricultural labor and had limited access to processed foods, resulting in lower rates of obesity and diet-related diseases. Moreover, the healthier lifestyle of 1890─1910 also benefited from reduced exposure to environmental pollutants and a more physically active daily routine, contributing to lower incidences of chronic respiratory ailments and cardiovascular conditions compared to modern sedentary lifestyles. The reduction of AS zero after 1940, or in other words the transformation of AS zero to higher AS, supports the implication of atherosclerosis as an actual civilization disease, caused the offset by different factors such as healthy metabolism, active lifestyle, more favourable body mass, lean diet, low blood lipids and cardiorespiratory health . Furthermore, famine not only impacts BMI but blood pressure. Consequently, subjects with higher AS might be the descendants of the mothers malnourished during WW II . As the prevalence of AS zero decreases and shifts towards higher AS categories, the curves for AS two and three rise. Similarly, around the mid-1960s, AS zero and two categories transition to AS three—marking the first crossover point. This correlation suggests that coronary heart disease mortality peaked in the 1960s. Since then, clinical manifestations of atherosclerosis have become the most frequent cause of death and one of the leading sources of morbidity, disability, and hospitalization today . The second cross (around 2005─2010) of the curves AS two and three shows the improvement in fighting the conditions causing atherosclerosis. This finding represents, that the more effective treatment methods have made a noticeable impact on the cardiovascular state. The development of commercial statins is a cornerstone in atherosclerotic management. In September 1987, lovastatin was given FDA approval to become the first commercial statin , . Statins have undergone extensive evaluation through numerous large-scale clinical trials, which encompassed a total of 90,000 participants who were observed over 5 years – . In all of these investigations, the outcomes consistently demonstrated that statin therapy reduces plasma LDL levels by 25–35% and diminishes the occurrence of heart attacks by 25–30%. Moreover, increased awareness has been accomplished, promoting a healthy lifestyle. Lack of smoking, BMI between 18.5 and 24.9, regular physical activity, moderate alcohol intake and healthy diet at mid-life is associated with a longer life expectancy free of major chronic diseases . The combination of these factors has led to a marked decrease in the AS three category. The marked increase in AS from the 1960s onward aligns with a shift in lifestyle, including the rise of processed foods and a more sedentary way of life, while the decrease observed after 2005 reflects the success of medical interventions, particularly the widespread use of statins and enhanced cardiovascular risk management. The most severe category, AS 4, exhibits minimal prevalence compared to the other scores. Our research group posits that this is due to subjects with ulcerated plaques potentially dying from cardiovascular causes, thereby being absent from this database. This finding bolsters the argument that our dataset is representative of the general healthy population. Local manifestation, sex differences in atherosclerosis score and age of onset.   An exciting aspect of the pathophysiology of atherosclerosis is the observation that arterial lesions show a non-random pattern in their development based on animal and human models, which correlates strongly with the arterial branch points and other regions of altered haemodynamics . In 1965, Mitchell and Schwartz found the appearance of lipid staining in the descending thoracic aorta based on autopsy studies , later in 1971, Caro and his co-workers pointed out the increased prevalence of fatty streaks in the initial segment abdominal aorta, caused by the increased inflow tract of the large branches . Similar distributions of atherosclerosis were established by subsequent research; however, none of them investigated six different regions in the same subjects – . Our findings help to clarify that atherosclerotic lesions occur first in the abdominal aorta, followed by the thoracic aorta, the ascending aorta, the carotid artery, coronary arteries, and finally the cerebral arteries.   Our study reports a much wider range of age (0─96 years) compared to the PDAY study (15─34 years), Bogalusa Heart Study (4─51 years), Muscatine Study (8─37 years) or Young Finns Study (8─45 years) , – . Nevertheless, it is worth noting that the PDAY study provides longitudinal data solely on the prevalence of different stages of atherosclerosis, but only within three vascular regions: the abdominal and thoracic aorta, and the right coronary artery. The broader age range and inclusion of three additional arterial regions (ascending aorta, cerebral arteries, and carotid arteries) enable us to construct a more precise understanding of the initiation of atherosclerosis in specific anatomical locations and explore potential gender disparities. Figure illustrates that atherosclerotic lesions appear already in the first decade of the lifetime in the abdominal aorta. This discovery regarding the early onset of atherosclerosis aligns with the primary findings of the PDAY study . Moreover it can be seen in Fig. b, that - similarly to all the other regions - in men this phenomenon appears earlier, which might stem from the female cardiovascular benefits caused by the ovarian sex steroid hormones until menopause . Around 55 years female subjects gain upon male subjects in our research. The manifestation of atherosclerosis in the investigated regions varies by around six and ten years between men and women, the lowest difference is presented in the abdominal aorta and cerebral arteries (six years), and the greatest difference is in the coronary arteries and in the carotid arteries (ten years) (Table ). Consequently, based on our observations, the peak prevalence of coronary heart disease in women is expected to occur approximately 6 to 10 years later than in men, a phenomenon supported by relevant literature .   Our research indicates that vascular aging may commence earlier in overweight individuals compared to their normal-weight counterparts in both sexes (Fig. a). Overweight and obesity are well-established risk factors for cardiovascular morbidity and mortality . However, age modifies this effect, and the two lines converge at around age 55. After this age range, the protective effect of normal weight might be lost and age can be considered as a risk factor in the same way as being overweight before the age of 55. In concordance with our previous result, Fig. b illustrates that males are more vulnerable to atherosclerosis until their mid-50s, at which point females become similarly affected by vascular ageing. These results indicate that risk stratification solely based on BMI is inadequate, as a normal-weight patient over 55 years of age faces a similar risk of atherosclerosis as their overweight counterpart. It will be crucial in the future to develop multifactorial risk assessment systems that enable personalized evaluations.   The conducted research is the largest autopsy-based database in Central Europe spanning nearly a century is unique considering the age range (0─96 years) and the case number (3400 subjects), covering six different vascular regions focusing on atherosclerosis. In Caucasian individuals, atherosclerosis begins as early as the first decade of life in both sexes, with the first degenerative changes occurring in the abdominal aorta. Based on our results BMI over 25 does increase the risk of atherosclerosis in every subject. The outcome of this study could provide clinical support for healthcare professionals in the more personalized therapy and encourage patient substantial compliance to treat atherosclerosis, thereby reducing cardiovascular morbidity and mortality.   Unfortunately, cardiovascular risk factors of the subjects and histopathological analysis of the investigated arterial regions were not available in the majority of the autopsy reports. Consequently, it was not possible to perform any further analysis including these factors of atherosclerosis. It is also important to underline, that the arterial regions were assigned with different AS scores merely based on the written autopsy reports. Since this is a retrospective study, observers of this working group were not able to take part in the autopsy procedures. A key limitation of this retrospective study is its reliance on pre-existing data, which may not allow for control of all potential confounding variables and limits the ability to establish causal relationships.   Below is the link to the electronic supplementary material. Supplementary Material 1   