Predicting Cardiovascular Risk Using Routine Mammograms in PostMenopausal Women

Dr. Gregory Weiss expounds on recent data indicating routine mammography in postmenopausal women could help identify women at increased risk of cardiovascular disease based on breast arterial calcification.

Cancer and heart disease are the leading killers of women in the United States.1 Sex-specific cardiovascular disease (CVD) markers have become an area of focus in cardiology. Even though women generally have lower burdens of obstructive coronary disease they are at higher risk for heart attack as their presenting event and have a worse prognosis than men following myocardial infarction.2

Mammography is a well-established screening tool for breast cancer. Current recommendations call for yearly screening mammograms to begin at age 45 with more frequent scans commencing at 55 years of age.2 With screening visits of any kind at a premium, any chance we get to screen for multiple health problems should be taken advantage of.

Around two-thirds of women attend their screening mammograms through all age groups with the exception of women in managed care who attend at a rate of 88.4%.3 While breast arterial calcification (BAC) is a common finding on routine mammograms, it has not been used as an indicator for further investigation.

Carlos Iribarren, MD, MPH, PhD, of Kaiser Permanente Northern California, along with colleagues sought to determine the association if any between BAC and atherosclerotic cardiovascular disease. To this end, the authors performed a cohort study of 5059 women between 60 and 79 years of age who had attended mammography screening during the study period. The primary outcome was incident hard atherosclerotic CVD in this population.

The results indicated that the presence of BAC on digital mammograms was independently associated with incident atherosclerotic CVD.2 In fact, Iribarren and his team found that women with BAC on mammogram had a 51% higher risk for heart disease and stroke than those without BAC.2 Further, women with BAC were 23% more likely to develop any type of CVD including stroke, heart failure, and peripheral arterial disease.2 While these results are promising the authors could find no dose-response association between total burden of BAC and atherosclerotic CVD.2

Iribarren points out that currently there is no standard for reporting or grading BAC. The authors suggest that grading technology could be incorporated in next-generation mammography equipment using a technology currently used to examine aortic arterial calcification.2

“We hope that our study will encourage an update of the guidelines for reporting breast arterial calcification from routine mammograms. Our study has moved the needle toward recommending routine assessment and reporting of breast arterial calcification in postmenopausal women,” Iribarren said.4

It should also be noted that no new screening visits or increased radiation dosage would be necessary to implement a BAC reporting practice since women would already be attending screening mammography visits regardless of a new recommendation to include BAC in the report. These findings give clinicians a tool already in use to improve sex specific risk stratification.

“Research has confirmed the calculators we currently use to assess an individual’s 10-year risk of developing cardiovascular disease are not as accurate in women as they are in men. In our current study, we evaluated if breast arterial calcification, which can be easily seen on a mammogram, provides more information about a woman’s risk of developing heart disease,” Iribarren added.4

Of note, while the authors found an association between the presence of BAC and risk for developing atherosclerotic cardiovascular disease, having no BAC did not translate into low risk for CVD.2 While BAC may emerge as an important screening tool for CVD more study is required before it’s routine use is adopted.

“Optimal risk factor control is equally important for all women with and without breast arterial calcification,” said Sadiya Khan, MD, MSc, FAHA, a cardiologist at Northwestern University.4

References:

  1. Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, et al.; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2021 update: a report from the American Heart Association.Circulation. 2021; 143:e254–e743. doi: 10.1161/CIR.0000000000000950
  2. Iribarren, C., MD, MPH, PhD, Chandra, M., MS, Lee, C., PhD, et al. Breast Arterial Calcification: a Novel Cardiovascular Risk Enhancer Among Postmenopausal Women,
  3. Oeffinger KC, Fontham ET, Etzioni R, Herzig A, Michaelson JS, Shih YC, Walter LC, Church TR, Flowers CR, LaMonte SJ, et al.; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society.JAMA. 2015; 314:1599–1614. doi: 10.1001/jama.2015.12783
  4. https://newsroom.heart.org/news/mammograms-may-provide-clues-about-womens-risk-for-cardiovascular-disease