Elderly women routinely undergo bone density testing using dual X-ray absorptiometry. These machines can also capture single-energy digital lateral spine images to detect spine fractures. Abdominal aortic calcification (AAC) is often seen on these images, however its long-term clinical importance remains uncertain. We assessed whether AAC from these images was associated with 14.5 year atherosclerotic vascular disease (ASVD) hospitalizations and deaths (stroke, coronary heart disease, heart failure and peripheral arterial disease) in 1,052 unselected ambulant, community-dwelling elderly women with a mean age of 75 years. Over 13,503 person years of follow-up 420 women suffered an ASVD hospitalization or death (206 ASVD-related deaths) identified using linked health records. Baseline Framingham Risk Scores (FRS) were calculated and AAC (24 point scale) was graded into three categories; low (scores 0 or 1), moderate (scores 2-5) and severe (scores .5). Low AAC was present in 471 women (45%), moderate AAC in 387 women (37%) and severe AAC in 194 women (18%). Absolute ASVD hospitalization or death risk by AAC severity was 37%, 39% and 49% respectively while ASVD death risk was 15%, 21% and 27% respectively. In Cox regression analyses women with severe AAC had an increased hazard ratio (HR) for 14.5-year ASVD hospitalizations or deaths; HR 1.51, 95%CI 1.18-1.94, P=0.001, while women with both moderate and severe AAC had an increased HR for ASVD death HR 1.47, 95%CI 1.07-2.01, P=0.018 and HR 1.93, 95%CI 1.35-2.76, P,0.001 respectively. The findings remained similar after adjustment for FRS. In conclusion abdominal aortic calcification identified on lateral spine imaging is associated with greater risk of long-term ASVD hospitalizations and/or deaths independent of traditional risk factors. These data support further investigations of the impact of lateral spine imaging to screen for atherosclerotic vascular disease risk at the time of bone density testing, on physician and patient management of modifiable cardiovascular disease risk factors, and ultimately, patient outcomes.