What is the significance of breast arterial calcification?

Significance of Breast Arterial Calcification

Breast arterial calcification (BAC) is a significant independent risk marker for cardiovascular disease (CVD) and should be considered a risk-enhancing factor for atherosclerotic cardiovascular disease (ASCVD) among women undergoing mammography. 1

What is Breast Arterial Calcification?

• BAC refers to medial calcification in the breast arteries that is commonly detected as an incidental finding during routine mammography screening 1
• BAC involves medial calcium deposits leading to arterial stiffening and is more closely related to comorbidities such as diabetes and hypertension, unlike coronary artery calcification (CAC) which represents intimal arterial calcium deposits 1
• BAC is present in approximately 26% of women aged 60-79 years undergoing screening mammography 1

Clinical Significance of BAC

Cardiovascular Risk Prediction

• BAC presence is significantly associated with increased hazard of ASCVD (HR 1.51 [95% CI 1.08-2.11]) after adjustment for traditional cardiovascular risk factors 1, 2
• BAC provides additional risk stratification beyond the pooled cohort equation, with an overall net reclassification improvement of 0.12 (95% CI 0.03-0.14) 1, 2
• BAC is independently associated with mortality and cardiovascular events, with adjusted hazard ratios of 1.49 (95% CI 1.33-1.67) for mortality and 1.56 (95% CI 1.41-1.72) for composite cardiovascular outcomes 3
• BAC is especially predictive of future cardiovascular events among younger women 3

Relationship with Coronary Artery Disease

• BAC on digital mammography predicts significant coronary artery disease (CAD-RADs ≥3) in symptomatic women 4
• BAC status can help identify women who may benefit from more aggressive cardiovascular risk management 1

Risk Factors Associated with BAC

• Increasing age is strongly associated with BAC (pooled OR 2.98 [95% CI 2.31-3.85] for every 10 years) 5
• Diabetes is associated with higher BAC prevalence (pooled OR 1.88 [95% CI 1.36-2.59]) 5
• Parity is associated with higher BAC prevalence compared to nulliparity (pooled OR 3.43 [95% CI 2.23-5.27]) 5
• Smoking is inversely associated with BAC prevalence (pooled OR 0.48 [95% CI 0.39-0.60]) 5
• No consistent associations have been found between BAC and hypertension, obesity, or dyslipidemia 5

Clinical Applications

• Women with BAC who fall into borderline or intermediate ASCVD risk categories may require more aggressive treatment 1
• Similarly, women with BAC who are already at high risk may need to have their therapy intensified 1
• Quantification of BAC beyond simple presence/absence adds incremental risk stratification, with each 10-point increase in BAC score associated with higher risk of mortality (HR 1.08 [95% CI 1.06-1.11]) 3
• Artificial intelligence algorithms can now quantify BAC, making it feasible to incorporate this information into clinical risk assessment 1, 3

Important Considerations

• BAC and CAC have different causes and pathophysiology, suggesting that BAC may contribute to cardiovascular disease through a pathway distinct from the intimal atherosclerotic process 1, 5
• Most studies to date have focused on BAC presence versus absence; research on BAC gradation for CVD risk prediction is still evolving 6
• Given the widespread use of mammography screening (approximately 70% of women in Europe), incorporating BAC assessment into cardiovascular risk screening could have substantial public health impact 1

Practical Implications

• BAC should be reported on mammography reports as it provides valuable cardiovascular risk information 1
• Patients with BAC on mammography should be considered for cardiovascular risk assessment and appropriate preventive interventions 1
• BAC can be used alongside traditional risk factors to better personalize cardiovascular risk assessment in women 1, 2