Association of breast arterial calcification and carotid intima-media thickness

Assessing cardiovascular risk with mammography and non-contrast chest CT: A review of the literature and clinical implications

Coronary artery disease (CAD) is the leading cause of mortality and disability globally. In the United States, about 7.2% of adults aged 20 and older are affected by CAD. However, due to its progression over decades, CAD is often undetected and unnoticed until plaque ruptures. This leads to partial or complete artery blockage, resulting in myocardial infarction. Thus, new screening methods for early detection of CAD are needed to prevent and minimize the morbidity and mortality from CAD. Vascular calcifications seen on mammography and non-contrast chest CT (NCCT) can be used for the early detection of CAD and are an accurate predictor of cardiovascular risk. This paper aims to review the basic epidemiology, pathophysiology, imaging findings, and correlation of long-term cardiovascular outcomes with vascular calcifications on mammography and NCCT.

Associations of Breast Arterial Calcifications with Cardiovascular Disease

Cardiovascular diseases (CVD), including coronary artery disease (CAD), continue to be the leading cause of global mortality among women. While traditional CVD/CAD prevention tools play a significant role in reducing morbidity and mortality among both men and women, current tools for preventing CVD/CAD rely on traditional risk factor-based algorithms that often underestimate CVD/CAD risk in women compared with men. In recent years, some studies have suggested that breast arterial calcifications (BAC), which are benign calcifications seen in mammograms, may be linked to CVD/CAD. Considering that millions of women older than 40 years undergo annual screening mammography for breast cancer as a regular activity, innovative risk prediction factors for CVD/CAD involving mammographic data could offer a gender-specific and convenient solution. Such factors that may be independent of, or complementary to, current risk models without extra cost or radiation exposure are worthy of detailed investigation. This review aims to discuss relevant studies examining the association between BAC and CVD/CAD and highlights some of the issues related to previous studies' design such as sample size, population types, method of assessing BAC and CVD/CAD, definition of cardiovascular events, and other confounding factors. The work may also offer insights for future CVD risk prediction research directions using routine mammograms and radiomic features other than BAC such as breast density and macrocalcifications.

Assessment of the Severity of Breast Artery Calcification on a Mammogram: Intraoperator and Interoperator Reproducibility

Purpose. To study approaches to the quantitative assessment of breast arterial calcification (BAC) – a new surrogate marker of high cardiovascular risk in women, to determine the most detailed way to quantify BAC and to assess the reproducibility of these parameters.

Material and methods. Mammograms of 1,078 women were analyzed for the presence of BAC. The intraoperator reproducibility of the assessment of the severity of BAC using a 12-point scale (Margolies L et al., 2016) was studied by analyzing 20 mammograms by the same operator twice with an interval of at least 2 weeks. Inter-operator reproducibility was studied by analyzing 99 mammograms by two independent operators.

Results. When assessing the intraoperative reproducibility of the total score for each mammary gland, the exact coincidence of the results was noted in 70% (95% confidence interval [CI] 53.5-83.4), in cases of difference of no more than 1 point – in 27.5% (95%CI 14.6-43.9), only in 1 case the difference in assessments was 2 points. No systematic error was found between the two measurements (p=1.0), the correlation coefficient was rs=0.973. The assessment of inter-operator reproducibility showed that the exact coincidence of indicators was present in 48.5% (95%CI 41.3-55.7), in 91.4% (95% CI 86.6-94.9) cases, the total score for each the mammary gland differed by no more than 1 point. There was no systematic error between the measurements of the two experts (p=0.438), the correlation coefficient was rs=0.942.

Conclusion. A good intraoperator and interoperator reproducibility of indicators of the severity of BAC on a 12-point scale has been shown, which makes it possible to recommend it for use in science and practice.

Breast Arterial Calcification Is Not Associated with Mild Cognitive Impairment or Incident All-Cause Dementia Among Postmenopausal Women: The MINERVA Study

Background: Since vascular risk factors are implicated in cognitive decline, and breast arterial calcification (BAC) is related to vascular risk, we postulated that BAC may be associated with cognitive impairment and dementia. Methods: We used a multiethnic cohort of 3,913 asymptomatic women 60-79 years of age recruited after mammography screening at a large health plan in 2012-2015. A BAC mass score (mg) was derived from digital mammograms. Cognitive function was measured at baseline using the Montreal Cognitive Assessment (MoCA) and incident all-cause dementia (n = 49 events; median follow-up = 5.6 years) were ascertained with validated ICD-9 and ICD-10 codes. We used cross-sectional linear regression of MoCA scores on BAC, then multinomial logistic regression predicting mild cognitive impairment not progressing to dementia and incident all-cause dementia and, finally, Cox regression of incident all-cause dementia. Results: No association by linear regression was found between MoCA scores and BAC presence in unadjusted or adjusted analysis. Women with severe (upper tertile) BAC had a MoCA score lower by 0.58 points (standard error [SE] = 0.18) relative to women with no BAC. However, this difference disappeared after multivariate adjustment. No significant associations were found in multinomial logistic regression for either BAC presence or gradation in unadjusted or adjusted analysis. No significant associations were found between BAC presence with incident all-cause dementia (fully adjusted hazard ratio = 0.74; 95% confidence interval: 0.39-1.39). Likewise, no significant association with incident all-cause dementia was noted for BAC gradation. Conclusions: Our results do not support the hypothesis that BAC presence or gradation may contribute to cognitive impairment or development of all-cause dementia.

Is breast arterial calcification associated with coronary artery disease?-A systematic review and meta-analysis

BACKGROUND

There is increasing evidence that breast arterial calcification (BAC), an incidental finding on 3-29% of mammograms, could be used to screen for coronary artery disease (CAD). We conducted a systematic review to assess the associations between BAC and CAD and its risk factors (hypertension, hypercholesterolemia, diabetes mellitus and smoking).

METHODS AND FINDINGS

MEDLINE and EMBASE databases and references of relevant papers were searched up to 18 February 2020 for English language studies that evaluated the associations of BAC and CAD and its risk factors. A single reviewer extracted all data and assessed study quality with verification by another independent reviewer, if required. Across 31 studies (n = 35,583; 3 longitudinal and 28 cross-sectional studies) that examined the association of BAC and CAD, the OR was 2.61 (95% CI 2.12-3.21; I2 = 71%). Sub-analysis of studies that graded BAC severity using the 4- (4 studies) or 12-point scale systems (3 studies) revealed an association with CAD and moderate-severe BAC (OR 4.83 (95%CI 1.50-15.54) and OR 2.95 (95%CI 1.49-5.84), respectively) but not mild BAC (OR 2.04 (95%CI 0.82-5.05) and OR 1.08 (95%CI 0.42-2.75), respectively). BAC was associated with hypertension (42 studies; n = 32,646; OR 1.80; 95% CI 1.47-2.21; I2 = 85%) and diabetes mellitus (51 studies; n = 53,464; OR 2.17; 95% CI 1.82-2.59; I2 = 75%) but not with hypercholesterolemia (OR 1.31; 95%CI 0.97-1.77; I2 = 67%). Smoking was inversely associated with BAC (35 studies; n = 40,002; OR 0.54; 95% CI 0.42-0.70; I2 = 83%). Studies mostly included symptomatic women. Marked heterogeneity existed and publication bias may be present.

CONCLUSIONS

BAC is associated with CAD, diabetes mellitus and hypertension and inversely associated with smoking. Whether BAC could screen for CAD cannot be determined from current published data due to the lack of larger prospective studies. A consensus approach to quantifying BAC may also facilitate further translation into clinical care. PROSPERO: CRD42020141644.

Association of vascular calcification of breast with carotid intima media thickness

Purpose

To assess the relationship between breast arterial calcification (BAC) on mammography and carotid intima medial thickness (C-IMT) by comparing these patients with healthy control subjects.

Material and methods

The study included 100 women divided into two groups based on presence of BAC on mammography using the WIPRO GE – DMR PLUS mammography unit. The groups included 50 BAC(+) (case group) and 50 BAC(–) (control group). BAC is defined as two linear calcific deposits forming the rail-road track pattern, with ring-like appearance in cross section. Relevant previous clinical and surgical history was taken and C-IMT was measured using B-mode ultrasonography Aplio XG (Toshiba medical systems corp., Japan) using an 8-13 MHz linear transducer within 1 cm from the proximal and distal portion of the common carotid artery and the mean value was taken.

Results

All the participants included in this study were within the age group of 40-70 years. Mean age with BAC(+) was 59.18 ± 8.59 years and BAC(–) was 50.70 ± 7.93 years. Mean C-IMT in the BAC(+) group was 0.86 ± 0.21 mm vs. 0.71 ± 0.12 mm in the BAC(–) group. Chi-square test, independent t test and Spearman’s rho correlation to assess the association of the breast arterial calcification were performed. The study showed significant difference in mean C-IMT between two groups (p value < 0.001) when correlated with age, diabetes, hypertension, presence of BAC and history of surgery and drug intake.

Conclusions

BAC in mammography is independently associated with C-IMT. Furthermore, apart from age and menopausal status a statistically significant positive correlation with C-IMT was observed.

Correlation between Breast Arterial Calcification and the 10-year fatal cardiovascular risk by means of the SCORE Risk System

Objectives:

The aim of this study was to investigate the relationship between Breast Arterial Calcification (BAC) on mammography and the 10-year fatal Cardiovascular Disease (CVD) risk by using SCORE risk system.

Methods:

The study was conducted from September 2013 to July 2014. A total of 66 women with BAC and 66 age-matched controls without BAC were analyzed. The groups were compared with respect to demographics, clinical, reproductive, laboratory parameters, and 10-year fatal CVD risk.

Results:

The mean ages of the women in the study was 54.0 years (40-85 years). Hypertension, systolic blood pressure, levels of serum total cholesterol and the calculated SCORE risk were higher in the BAC (+) group than in the BAC (-) group (p=0.04, p=0.031, p=0.046, and p=0.038 respectively). Multivariate analysis showed that none of them was independent factor of BAC on mammograms, only the 10-year fatal CVD risk was close to being statistically significant (OR:1.17, CI:0.98-1.38, p=0.06).

Conclusion:

BAC on mammography was found to be related to the 10-year fatal CVD risk as calculated by the SCORE risk score system. Additional large-scale prospective studies are required to further assess whether BAC can be considered a useful screening tool for CVD risk prediction in women who screened for breast cancer by mammography.

Association of breast arterial calcification and osteoporosis in Turkish women

Objective:

Breast arterial calcification (BAC), medial calcific sclerosis of small to medium-sized muscular arteries, is a benign finding of mammographic evaluation. Previous studies have shown the relationships between BAC and systemic disorders such as cardiovascular disease, diabetes mellitus and hypertension. The aim of this study was to determine the association between reduced bone mineral density and BAC.

Methods:

The study population consisted of 567 women who had both mammography and bone mineral density evaluation. BAC (+) and BAC (-) women were compared for age, body mass index, postmenopausal duration, number of deliveries, breastfeeding duration, DM, HT, lipid treatment, osteopenia, and osteoporosis.

Results:

BAC was seen in mammographic evaluation of 179 women and 388 subjects without BAC accepted as the control group. There was a statistically significant relationship between age, postmenopausal duration, number of deliveries, history of DM, HT, lipid treatment and BAC. While the prevalence of osteopenia was higher in control group (52.8%), the rate of osteoporosis (48.7%) was higher in group with BAC.

Conclusion:

There was statistically significant relationship between BAC and osteoporosis in postmenopausal women. Determination of BAC in routine screening mammography might be helpful in both identifying women with risk of cardiovascular disease and osteoporosis.

WITHDRAWN: Digital breast arterial calcium score is predictive of coronary calcium score

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Evaluating the Association between Breast Arterial Calcification and Carotid Plaque Formation

OBJECTIVE

We aimed to evaluate the association between breast arterial calcification (BAC) and carotid plaque formation.

MATERIALS AND METHODS

The study group comprised 47 consecutive BAC (+) women, whereas the control group comprised 33 BAC (-) women (total, 80 women). All mammograms were examined by a specialist without being any apartheid that it was come from central or not. For the exist and density of calcification was used classification method. When we evaluate carotid arterial plaque with Doppler US used scale method. For analyzing categorical variables, we used chi-square test, and for numeric variables, we used independent t-test.

RESULTS

As nearly all BAC+ women had all types of carotid plaques, weighted of them was found that they were fatty plaque type (n=13 %46.4). Only one BAC+ patient was grade 2 and had no carotid plaques (n=1 %3.6). MAK- patients had nearly no plaque types.

CONCLUSION

Breast cancer mammographic evaluation is an already important, cheap, and simple imaging method. In our study, we report a similar cheap, simple method that can be useful for evaluating atherothrombotic atherosclerosis, which is the most important cause of ischemic infarct.

Breast arterial calcifications: a systematic review and meta-analysis of their determinants and their association with cardiovascular events

OBJECTIVE

Breast arterial calcifications (BAC), regularly observed at mammography, are medial calcifications and as such an expression of arteriosclerosis. Our objective was to evaluate and summarize the available evidence on the associations of BAC with cardiovascular risk factors and cardiovascular risk.

METHODS

A systematic literature review and meta-analysis were conducted. Embase and PubMed databases were searched. After critical appraisal, odds ratios were extracted from studies of moderate or good quality that examined risk factors for BAC or associations of BAC with cardiovascular disease. Random effects model meta-analyses were used to calculate pooled odds ratios and 95% confidence intervals (95%CIs).

RESULTS

BAC prevalence is around 12.7% among women in breast cancer screening programs. Increasing age (pooled OR 2.98 [95%CI 2.31-3.85] for every 10 years), diabetes (pooled OR: 1.88 [95%CI 1.36-2.59]) and parity as opposed to nulliparity (pooled OR 3.43 [95%CI 2.23-5.27]) are associated with higher BAC prevalence. Smoking is associated with lower BAC prevalence (pooled OR 0.48 [95%CI 0.39-0.60]). No associations were found with hypertension, obesity or dyslipidemia. Although longitudinal studies (n = 3) were scarce, BAC appear to be associated with an increased risk of cardiovascular disease events (adjusted hazard ratios for coronary heart disease ranging from 1.32 [95%CI 1.08-1.60] to 1.44 [95%CI1.02-2.05]).

CONCLUSION

BAC appear to be associated with an increased risk of cardiovascular disease events, while only being associated with some of the known cardiovascular risk factors, illustrating that medial arterial calcification might contribute to cardiovascular disease through a pathway distinct from the intimal atherosclerotic process.

Mammographically detectable breast arterial calcification and atherosclerosis

Breast arterial calcification (BAC), observed as an incidental finding on screening mammograms, represents degenerative calcific changes occurring in the mammary arteries, with increasing age. The aim of this review is to discuss relevant literature examining relation between BAC and atherosclerosis. After a thorough literature search, in OVID and PubMed, 199 studies were identified, of which 25 were relevant to our review. Data were abstracted from each study and statistical analysis was done, including calculation of odds ratios and construction of forest plots. A total of 35,542 patients were enrolled across 25 studies looking at an association between BAC and coronary artery disease, cardiovascular disease, stroke, cerebral artery disease, carotid and peripheral artery diseases, and coronary artery calcification. A majority of the studies showed a statistically significant relation between BAC and presence of coronary artery disease cardiovascular disease and associated mortality. Sensitivity of BAC in predicting cardiovascular events was low, but specificity was high. BAC was predictive of incident and prevalent stroke but not mortality of stroke. Similarly, BAC was predictive of cerebral, carotid, and peripheral artery diseases. The role of BAC as a surrogate marker of coronary and systemic atherosclerosis is currently uncertain. Its role may be further elucidated by more large-scale prospective studies and clinical experience.

The association of breast arterial calcification and metabolic syndrome

OBJECTIVES

We investigated the relationship between metabolic syndrome and breast arterial calcification detected via mammography in a cohort of postmenopausal subjects.

METHODS

Among 837 patients referred to our radiology department for mammographic screening, 310 postmenopausal females (105 patients with and 205 patients without breast arterial calcification) aged 40 to 73 (mean 55.9 ± 8.4) years were included in this study. The groups were compared with respect to clinical characteristics and metabolic syndrome criteria. Univariate and multivariate analyses identified the factors related to breast arterial calcification.

RESULTS

Age, postmenopausal duration and the frequencies of diabetes mellitus, hypertension and metabolic syndrome were significantly higher in the subjects with breast arterial calcification than in those without (p<0.05). Multivariate analysis indicated that age (OR=1.3, 95% CI=1.1-1.6, p=0.001) and metabolic syndrome (OR=4.0, 95% CI=1.5-10.4, p=0.005) were independent predictors of breast arterial calcification detected via mammography. The independent predictors among the features of metabolic syndrome were low levels of high-density lipoproteins (OR=8.1, 95% CI=1.0-64.0, p=0.047) and high blood pressure (OR=8.7, 95% CI=1.5-49.7, p=0.014).

CONCLUSIONS

The likelihood of mammographic detection of breast arterial calcification increases with age and in the presence of hypertension or metabolic syndrome. For patients undergoing screening mammography who present with breast arterial calcification, the possibility of metabolic syndrome should be considered. These patients should be informed of their cardiovascular risk factors and counseled on appropriate lifestyle changes.

Breast Arterial Calcification: a New Marker of Cardiovascular Risk?

Mammographically-detected breast arterial calcifications (BAC) are considered to be an incidental finding without clinical importance since they are not associated with increased risk of breast cancer. The goal of this article is to review existing evidence that the presence of BAC on mammography correlates with several (but not all) traditional cardiovascular disease (CVD) risk factors and with prevalent and incident CVD. Thus, BAC detected during routine mammography is a noteworthy finding that could be valuable in identifying asymptomatic women at increased future CVD risk that may be candidates for more aggressive management. In addition, there are notable differences in measures of subclinical atherosclerosis burden in women (ie, coronary artery calcification) by race/ethnic background, and the same appears to be true for BAC, although data are very limited. Another noteworthy limitation of prior research on BAC is the reliance on absence vs presence of BAC; no study to date has determined gradation of BAC. Further research is thus required to elucidate the role of BAC gradation in the prediction of CVD outcomes and to determine whether adding BAC gradation to prediction models based on traditional risk factors improves classification of CVD risk.

Risk factors associated with breast arterial calcifications

BACKGROUND

A number of studies have linked the presence of breast arterial calcifications (BACs) with an increased risk of diabetes, hypertension, coronary artery disease (CAD), and cardiovascular mortality. Because there is a well-established screening system for breast cancer, it has been proposed that the presence of BACs can be used as a warning sign indicating an increased risk of metabolic and vascular diseases.

PURPOSE

To determine the relation between BAC and early renal dysfunction.

MATERIAL AND METHODS

A retrospective review of 6118 mammograms identified 701 cases with BACs. Women with BACs were compared to a random selection of 362 women without BACs based on available laboratory data. Univariate analysis was conducted according to age groups.

RESULTS

The prevalence of BACs was 11.5% in our study. Hyperglycemia increased the odds of BACs by 8.1 (95% CI 3.0-22.1, P < 0.001) in the 50-59-year age group. The presence of an elevated blood urea nitrogen (BUN) and serum creatinine increased the odds of BACs by 2.6 (95% CI 1.2-6.0, P = 0.016) and 2.3 (95% CI 1.0-5.2, P = 0.045) in women ≥70 years of age. Hyperlipidemia was not a significant risk factor for BACs in any age group.

CONCLUSION

Our results support the view that the presence of BACs on mammography may be indicative of diabetes in middle-aged women. On the other hand, BACs are not very useful for predicting early renal dysfunction in women <70 years of age.

Mammograms and breast arterial calcifications: looking beyond breast cancer: a preliminary report

BACKGROUND

To find out the prevalence, clinical and biochemical correlates of Breast Artery Calcification (BAC) in the Nigerian women.

FINDINGS

This is a cross sectional study involving 54 consecutive adult female subjects sent to the Radiology Department of the Lagos State University Teaching Hospital (LASUTH), Ikeja-Lagos, Nigeria for screening and diagnostic mammography. The study was carried out for a period of five months.The prevalence of BAC was 20%. Ageing was found to be related to BAC. Cardiovascular risk factors including diabetes mellitus (DM), hypertension, obesity, alcohol ingestion, use of oral contraceptives and hormone replacement therapy, were not significantly related to the presence of BAC in this study.

CONCLUSION

This study showed that though the presence of BAC in a mammogram is related to age, it may not predict or serve as a significant marker for cardiovascular diseases (CVD) in women in our environment.

Breast arterial calcification: a marker of medial vascular calcification in chronic kidney disease

BACKGROUND AND OBJECTIVES

Because previous studies have not distinguished between intimal (atherosclerotic) and medial vascular calcification, the prevalence and clinical significance of either condition in chronic or end-stage kidney disease (CKD or ESKD) are unknown. We hypothesized that breast arterial calcification (BAC) is exclusively medial and that mammography can serve as a useful marker of generalized medial calcification in CKD and ESKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Arterial calcification was identified histologically in breast tissue or visually in mammograms and radiographs of extremities from patients with CKD or ESKD.

RESULTS

Medial calcification but no intimal calcification was present in all 16 specimens from patients with CKD or ESKD. In 71 women with ESKD, BAC was present on mammograms in 63% compared with 17% in women without renal insufficiency matched for age, race, and diabetes (P<0.001). Age and ESKD duration were significant, independent predictors of BAC. BAC was also present in 36% of mammograms from the same patients performed 5.5±0.7 years before the onset of ESKD (P<0.05 versus control) but in only 14% of patients with stage 3 CKD. Comparison of mammograms and extremity radiographs revealed that BAC was present in over 90% of patients with peripheral arterial calcification (PAC), and PAC was observed in less than 6% of patients without BAC.

CONCLUSIONS

BAC is a specific and useful marker of medial vascular calcification in CKD, and its prevalence is markedly increased in ESKD and advanced CKD.