Calcification of breast artery as detected by mammography: association with coronary and aortic calcification

Opportunistic screening at chest computed tomography: literature review of cardiovascular significance of incidental findings

Background and Objective

Several incidental cardiovascular findings are present in a routine chest computed tomography (CT) scan, many of which do not make it to the final radiology report. However, these findings have important clinical implications, particularly providing prognosis and risk-stratification for future cardiovascular events. The purpose of this article is to review the literature on these incidental cardiovascular findings in a routine chest CT and inform the radiologist on their clinical relevance.

Methods

A time unlimited review of PubMed and Web of Science was performed by using relevant keywords. Articles in English that involved adults were included.

Key Content and Findings

Coronary artery calcification (CAC) is the most common incidental cardiac finding detected in a routine chest CT and is a significant predictor of cardiovascular events. Noncoronary vascular calcifications in chest CT include aortic valve, mitral annulus, and thoracic aortic calcifications (TAC). Among these, aortic valve calcification (AVC) has the strongest association with coronary artery disease and cardiovascular events. Additional cardiac findings such as myocardial scar and left ventricular size and noncardiac findings such as thoracic fat, bone density, hepatic steatosis, and breast artery calcifications can also help in risk stratification and patient management.

Conclusions

The radiologist interpreting a routine chest CT should be cognizant of the incidental cardiovascular findings, which helps in the diagnosis and risk-stratification of cardiovascular disease. This will guide appropriate referral and management.

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.

Relationship between Arterial Calcifications on Mammograms and Cardiovascular Events: A Twenty-Three Year Follow-Up Retrospective Cohort Study

PURPOSE

Breast arterial calcifications (BAC) have been associated with cardiovascular diseases. We aimed to examine whether the presence of BAC could predict the development of cardiovascular events in the very long term, as evidence has suggested.

PATIENTS AND METHODS

We conducted a 23-year follow-up retrospective cohort study considering women specifically studied for breast cancer. After reviewing the mammograms of 1759 women, we selected 128 patients with BAC and an equal number of women without BAC.

RESULTS

Women with BAC had higher relative risk (RR) for cardiovascular events, globally 1.66 (95% CI): 1.31-2.10 vs. 0.53 (0.39-0.72), and individually for ischemic heart disease 3.25 (1.53-6.90) vs. 0.85 (0.77-0.94), hypertensive heart disease 2.85 (1.59-5.09) vs. 0.79 (0.69-0.89), valvular heart disease 2.19 (1.28-3.75) vs. 0.83 (0.73-0.94), congestive heart failure 2.06 (1.19-3.56) vs. 0.85 (0.75-0.96), peripheral vascular disease 2.8 (1.42-5.52) vs. 0.85 (0.76-0.94), atrial fibrillation 1.83 (1.09-3.08) vs. 0.86 (0.76-0.98), and lacunar infarction 2.23 (1.21-4.09) vs. 0.86 (0.77-0.96). Cox's multivariate analysis, also considering classical risk factors, indicated that this BAC was significantly and independently associated with survival (both cardiovascular event-free and specific survival; 1.94 (1.38-2.73) and 6.6 (2.4-18.4)).

CONCLUSIONS

Our data confirm the strong association of BAC on mammograms and the development cardiovascular events, but also evidence the association of BAC with cardiovascular event-free and specific survival.

The association between incidentally found breast arterial calcification on routine screening mammography and the development of coronary artery disease and stroke: results of a 10-year prospective study

OBJECTIVE

The objective of this study is to assess whether the presence of breast arterial calcifications (BACs) found on routine mammography is prospectively associated with the development of cardiovascular disease (CVD) events after 10 years of follow-up.

METHODS

Women presenting for screening mammography were enrolled in this prospective cohort. Baseline data were collected including history of CVD and CVD risk factors. Mammograms were assessed for the presence or absence of BAC. Participants completed questionnaires 10 years after baseline that assessed the development of CVD (coronary artery disease [CAD] and stroke) and CVD risk factors.

RESULTS

Of the 1,995 participants who enrolled at baseline, complete 10-year follow-up data were available for 1,039; of those, 114 (11.0%) were BAC-positive and 925 (89.0%) were BAC-negative at baseline. After controlling for age, BAC-positive women were more likely to develop CAD (odds ratio, 3.14; 95% confidence interval, 1.86-5.27; P < 0.001) compared with BAC-negative women after 10 years of follow-up. After controlling for age, BAC-positive women were more likely to have had a stroke (odds ratio, 5.10; 95% CI, 1.82-14.30) compared with BAC-negative women after 10 years.

CONCLUSIONS

The presence of BAC on routine screening mammography was associated with a significantly increased risk of developing CAD and stroke after 10 years of follow-up. Additional large prospective, population-based studies are needed to confirm BAC as a predictor of future CVD events and its utility in stratifying a woman's risk of CVD.

Breast arterial calcification and epicardial adipose tissue volume, but not density are independently associated with cardiovascular risk

BACKGROUND

Mammographically detected breast arterial calcification (BAC) has been proposed as surrogate marker for coronary artery disease (CAD) in women. Epicardial adipose tissue (EAT) and peri-coronary adipose tissue (PCAT) are inflammatory fat depots linked to atherogenesis. BAC has demonstrated association with inflammation, therefore we aimed to determine the association between BAC, EAT and PCAT.

METHODS

Single-centre, retrospective, cross-sectional study of women with digital mammography and coronary computed tomography angiography (CCTA). EAT and PCAT were quantitively assessed using semi-automated software. Patient demographics and cardiovascular risk factors were obtained from medical records and mammograms reviewed for BAC. Pre-test cardiovascular risk was determined with CAD Consortium Score. Chi-square, t-test and Mann-Whitney U tests were used to assess between group differences. Multivariable linear and logistic regression modelling was conducted to adjust for confounders.

RESULTS

Among 153 patients (age 61, SD 11) included in this study, BAC was present in 37 (24%) patients. BAC-positive patients had higher EAT volume (EATv) (110.2 mL, SD 41 mL vs 94.4 mL, SD 41 mL, p = 0.02) but this association was not significant after adjusting for cardiovascular risk factors (p = 0.26). BAC did not associate with EAT density or PCAT. BAC and EATv were strongly associated with cardiovascular risk and CAD independent of each other: CV risk (BAC OR 7.55 (3.26-18.49), p < 0.001, EATv OR 1.02 (1.01-1.03), p < 0.001), CAD presence (BAC OR 4.26 (1.39-13), p = 0.01; EATv OR 1.01 (1.0-1.03), p = 0.04).

CONCLUSION

BAC and EATv are independent predictors of CV risk and CAD, but don't independently associate with each other, the relationship confounded by shared cardiovascular risk factors. BAC doesn't appear to associate with adipose tissue density and its presence may be cumulative result of long-term exposure to CV risk factors.

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.