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Prioritizing Health | Mammography as a Window Into CV Health

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Prioritizing Health | Mammography as a Window Into CV Health

Mar 01, 2026

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Most women over 40 years old in the U.S. undergo annual or biennial screening mammography, and these images often reveal more than malignancy alone.1 A common incidental finding is breast arterial calcifications (BAC) - calcium deposition within the medial layer of small- to medium-sized arteries, also referred to as Mockenberg medial calcific sclerosis.2

Mammography as a Window Into CV Health

The prevalence of BAC increases steadily with age, from about 10% of women at age 40 and increasing to 50% by age 80.3 Unlike coronary artery calcifications (CAC), BAC do not cause luminal narrowing.2,4 Although they are not obstructive, BAC are increasingly recognized as a clinically meaningful marker of cardiovascular risk.5,6 Strong associations between BAC and cardiovascular disease (CVD) have been shown, including a threefold increase in coronary artery disease (CAD) and a fivefold increase in stroke over 10 years.7,8

Interestingly, the diagnostic performance of BAC is strongest in younger women. The highest diagnostic accuracy of 93% for detecting CAC was shown in women <60 years.9 Moreover, quantification of BAC is relevant, with moderate to severe BAC a greater predictor of CAD than mild BAC.10 BAC have been associated with increased incidence of CAD, stroke, heart failure, diabetes and cardiovascular mortality.2,4,7,11

The prognostic significance of BAC has been clarified further in well-designed, contemporary studies. Its presence was independently associated with increased risk of atherosclerotic cardiovascular disease (ASCVD) and global CVD.8 Another study showed that after adjusting for traditional cardiovascular risk factors, BAC were most predictive of CVD and all-cause mortality in women <60.3

As BAC become increasingly common with advanced age, its prognostic discriminatory value diminishes. Conversely, evidence suggests BAC may develop at an earlier age than traditional CVD risk factors, further demonstrating its potential as an early marker of CVD in younger patients.3 Together, these findings highlight the potential role of BAC as a clinically meaningful biomarker of cardiovascular risk in women with particular relevance in early risk identification.

Unmet Need in Women's CV Health

Heart disease remains the leading cause of death in women worldwide, yet risk stratification remains a challenge. In part, this is because commonly used tools, such as the pooled cohort equation, tend to underestimate risk in female populations, particularly in younger women and non-White patients.12-15 Much of the historical medical evidence guiding cardiovascular care was derived from clinical trials that excluded or underrepresented female participants.

Women experience increased in-hospital mortality and decreased mean survival time after an acute coronary syndrome vs. men.16 As such, there is a critical need for innovative, sex-specific screening strategies to improve early identification of at-risk women. BAC present an opportunity to leverage an existing, widely utilized test for cardiovascular risk assessment.

Current Limitations

Despite growing interest in BAC, several limitations hinder its routine clinical integration.

First, the clinical significance of BAC remains incompletely defined, leading to uncertainty and inconsistent interpretation among clinicians. Much of the existing data is derived from observational studies, limiting generalizability and causality.17 Second, no prospective, randomized trials have established whether intensified preventive strategies based on presence of BAC translate into improved cardiovascular outcomes. Third, the lack of standardized reporting practices remains a significant barrier. There are currently no U.S. or international guidelines for BAC reporting, and radiologists do not uniformly document its presence or absence.18 Current reporting approaches, including visual binary assessment, semi-quantitative grading and automated methods, vary widely. Additional data are needed to determine which method best balances accuracy, reproducibility and clinical relevance.18

Practical Approaches For Clinicians

In the absence of definitive guidelines, clinicians must take a pragmatic approach when BAC are identified on screening mammography. Although current primary prevention guidelines do not classify BAC as a formal risk-enhancing factor, emerging data suggest an association with outcomes.8 Moderate to severe BAC, particularly when identified in women <60 years, could be a cost-effective measure of CVD risk, if routinely reported and documented. Shared decision-making with the patient is essential, emphasizing the uncertainty of the evidence while acknowledging the potential implications for increased cardiovascular risk, similar with other extracoronary calcifications. For patients with BAC, it is reasonable to reinforce lifestyle-based risk reduction and, in select cases, CAC evaluation to further inform primary prevention strategies.

Future Directions

While BAC is a promising cardiovascular risk marker, to establish its clinical role, standardized reporting and integration into risk assessment are needed, particularly given most radiologists observe BAC and most women wish to be informed of this.18,19 Prospective randomized studies are needed to determine whether BAC-guided prevention improves outcomes, and advances in AI may enable consistent, scalable implementation. Targeted clinician education, including primary care physicians, gynecologists and preventive cardiologists, will be essential to ensure appropriate interpretation and patient-centered use of BAC in preventive care.

Clinician Takeaways

  1. Breast arterial calcifications (BAC) are common findings on routine screening mammograms that represent nonobstructive vascular calcifications but are associated with increased cardiovascular risk.
  2. Although their pathophysiology is distinct from atherosclerosis, BAC are strongly associated with cardiovascular disease, including increased risk of coronary artery disease, stroke, heart failure, diabetes and mortality.
  3. The prognostic value of BAC predicting cardiovascular risk is greatest in women younger than 60 years, particularly when BAC is moderate-severe.
  4. BAC may serve as an early, sex-specific cardiovascular risk marker that addresses limitations of traditional risk calculators, which can underestimate risk in young and non-White women.
  5. In the absence of guidelines, BAC should prompt shared decision-making, reinforcement of lifestyle prevention, and selective use of further risk assessment (for example, CAC evaluation), while acknowledging current evidence limitations and variability in reporting.

Patient Takeaways

  1. Breast arterial calcifications (BAC) are a common finding on mammograms and are not cancer but rather show calcium in the blood vessels within the breast.
  2. Finding BAC does not mean you have heart disease now, but it may be linked to a higher risk of heart problems later in life.
  3. BAC may be most useful in identifying younger patients at risk of heart disease, particularly when traditional risk calculators may miss it.
  4. There are no formal guidelines for treatment of BAC yet, but if it is identified, it may be a good time to review your heart health and risk factors with your doctor.
  5. If BAC is reported, focusing on AHA's Life's Essential 8 (eat better, be more active, quit tobacco, get healthy sleep, manage weight, control cholesterol, manage blood sugar and manage blood pressure) are critical to achieving long-term heart health.

This article was authored by Rachel Drummey, MD, and Lily Dastmalchi, DO, MA, FACC, at Inova Schar Heart and Vascular Institute, Inova Health System, Falls Church, VA, and members of ACC's Prevention of Cardiovascular Disease Member Section. Learn more and join.

References

  1. Howard DH, Tangka FKL, Miller J, Sabatino SA. Variation in state-level mammography use, 2012 and 2020. Public Health Rep. 2024;139(1):59-65. doi:10.1177/00333549231155876.
  2. Rossi J, Cho L, Newell MS, et al. Breast arterial calcifications on mammography: a review of the literature. J Breast Imaging. 2025;7(3):268-279. doi:10.1093/jbi/wbaf009
  3. Allen TS, Bui QM, Petersen GM, et al. Automated breast arterial calcification score is associated with cardiovascular outcomes and mortality. JACC Adv. Nov 2024;3(11):101283. doi:10.1016/j.jacadv.2024.101283
  4. Ibrahim M, Suleiman ME, Gandomkar Z, et al. Associations of breast arterial calcifications with cardiovascular disease. J Womens Health (Larchmt). May 2023;32(5):529-545. doi:10.1089/jwh.2022.0394
  5. Seifi B, Javadrashid R, Seifi F, et al. Breast artery calcification as a predictor of coronary artery calcification: a cross-sectional study. Pol J Radiol. 2020;85:e369-e374 doi:10.5114/pjr.2020.97932.
  6. Margolies L, Salvatore M, Hecht HS, et al. Digital mammography and screening for coronary artery disease. JACC Cardiovasc Imaging. 2016;9(4):350-60. doi:10.1016/j.jcmg.2015.10.022
  7. Hendriks EJ, de Jong PA, van der Graaf Y, et al. Breast arterial calcifications: a systematic review and meta-analysis of their determinants and their association with cardiovascular events. Atherosclerosis. 2015;239(1):11-20. doi:10.1016/j.atherosclerosis.2014.12.035
  8. Iribarren C, Chandra M, Lee C, et al. Breast arterial calcification: a novel cardiovascular risk enhancer among postmenopausal women. Circ Cardiovasc Imaging. 2022;15(3):e013526. doi:10.1161/CIRCIMAGING.121.013526
  9. Minssen L, Dao TH, Quang AV, et al. Breast arterial calcifications on mammography: a new marker of cardiovascular risk in asymptomatic middle age women? Eur Radiol. 2022;32(7):4889-4897. doi:10.1007/s00330-022-08571-3
  10. Lee SC, Phillips M, Bellinge J, et al. Is breast arterial calcification associated with coronary artery disease? A systematic review and meta-analysis. PLoS One. 2020;15(7):e0236598. doi:10.1371/journal.pone.0236598
  11. Osman M, Regner S, Osman K, et al. Association between breast arterial calcification on mammography and coronary artery disease: A systematic review and meta-analysis. J Womens Health (Larchmt). 2022;31(12):1719-1726. doi:10.1089/jwh.2020.8733
  12. Martin SS, Aday AW, Almarzooq ZI, et al. 2024 heart disease and stroke statistics: A report of US and global data from the American Heart Association. Circulation. 2024;149(8):e347-e913. doi:10.1161/CIR.0000000000001209
  13. Roxane H, Pedro MV, Julien V. External validation of the 2023 American Heart Association Predicting Risk of cardiovascular disease EVENTs equations for atherosclerotic cardiovascular disease in primary cardiovascular prevention setting and comparison with 2021 Systematic COronary Risk Evaluation and 2013 Pooled Cohort Equations. Eur J Prev Cardiol. 2025;doi:10.1093/eurjpc/zwaf213
  14. Medina-Inojosa JR, Somers VK, Garcia M, et al. Performance of the ACC/AHA pooled cohort cardiovascular risk equations in clinical practice. J Am Coll Cardiol. 2023;82(15):1499-1508. doi:10.1016/j.jacc.2023.07.018
  15. Cho SMJ, Levin M, Chen R, et al. AHA PREVENT equations and cardiovascular disease risk in diverse health care populations. J Am Coll Cardiol. 2025;86(3):181-192. doi:10.1016/j.jacc.2025.04.066
  16. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 Update: A report from the American Heart Association. Circulation. 2022;145(8):e153-e639. doi:10.1161/CIR.0000000000001052
  17. Bui QM, Daniels LB. A review of the role of breast arterial calcification for cardiovascular risk stratification in women. Circulation. 2019;139(8):1094-1101. doi:10.1161/CIRCULATIONAHA.118.038092
  18. Brown AL, Wahab RA, Zhang B, et al. Reporting and perceptions of breast arterial calcification on mammography: A survey of ACR radiologists. Acad Radiol. 2022;29 Suppl 1:S192-S198. doi:10.1016/j.acra.2021.01.027
  19. Margolies LR, Yip R, Hwang E, et al. Breast arterial calcification in the mammogram report: the patient perspective. AJR Am J Roentgenol. 2019;212(1):209-214. doi:10.2214/AJR.18.20171

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Keywords: Cardiology Magazine, ACC Publications, CM-Mar-2026, Mammography, Breast Neoplasms, Women's Health Services