Breast Arterial Calcification: A Potential Surrogate Marker for Cardiovascular Disease

Deep transfer learning for detection of breast arterial calcifications on mammograms: a comparative study

INTRODUCTION

Breast arterial calcifications (BAC) are common incidental findings on routine mammograms, which have been suggested as a sex-specific biomarker of cardiovascular disease (CVD) risk. Previous work showed the efficacy of a pretrained convolutional network (CNN), VCG16, for automatic BAC detection. In this study, we further tested the method by a comparative analysis with other ten CNNs.

MATERIAL AND METHODS

Four-view standard mammography exams from 1,493 women were included in this retrospective study and labeled as BAC or non-BAC by experts. The comparative study was conducted using eleven pretrained convolutional networks (CNNs) with varying depths from five architectures including Xception, VGG, ResNetV2, MobileNet, and DenseNet, fine-tuned for the binary BAC classification task. Performance evaluation involved area under the receiver operating characteristics curve (AUC-ROC) analysis, F1-score (harmonic mean of precision and recall), and generalized gradient-weighted class activation mapping (Grad-CAM++) for visual explanations.

RESULTS

The dataset exhibited a BAC prevalence of 194/1,493 women (13.0%) and 581/5,972 images (9.7%). Among the retrained models, VGG, MobileNet, and DenseNet demonstrated the most promising results, achieving AUC-ROCs > 0.70 in both training and independent testing subsets. In terms of testing F1-score, VGG16 ranked first, higher than MobileNet (0.51) and VGG19 (0.46). Qualitative analysis showed that the Grad-CAM++ heatmaps generated by VGG16 consistently outperformed those produced by others, offering a finer-grained and discriminative localization of calcified regions within images.

CONCLUSION

Deep transfer learning showed promise in automated BAC detection on mammograms, where relatively shallow networks demonstrated superior performances requiring shorter training times and reduced resources.

RELEVANCE STATEMENT

Deep transfer learning is a promising approach to enhance reporting BAC on mammograms and facilitate developing efficient tools for cardiovascular risk stratification in women, leveraging large-scale mammographic screening programs.

KEY POINTS

• We tested different pretrained convolutional networks (CNNs) for BAC detection on mammograms. • VGG and MobileNet demonstrated promising performances, outperforming their deeper, more complex counterparts. • Visual explanations using Grad-CAM++ highlighted VGG16's superior performance in localizing BAC.

Association Between Breast Arterial Calcifications and Cardiovascular Disease: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have shown that breast arterial calcification (BAC) detected on screening mammography is linked to cardiovascular diseases via medial calcification. However, its effect on cardiovascular outcomes remains unclear. Therefore, we conducted a meta-analysis to determine the effect of BAC on cardiovascular outcomes in patients.

METHODS

Three electronic databases (Pubmed, Embase, and Scopus) were searched on May 1, 2022, for studies examining the relationship between BAC and cardiovascular outcomes including cardiac death, acute myocardial infarction, ischemic heart disease, stroke, peripheral artery disease, and heart failure. A random-effects meta-analysis model was used to summarise the studies.

RESULTS

A total of 5 longitudinal studies were included with a combined cohort of 87,865 patients. Significantly, the pooled risk ratio (RR) of the association between BAC and cardiac death was 2.06 (P < 0.00001). BAC was associated with a significantly increased risk of developing other cardiovascular diseases, such as ischemic/hemorrhagic stroke (RR 1.51; P = 0.003), ischemic stroke (RR 1.82; P < 0.00001), peripheral vascular disease (RR 1.24; P = 0.003), and heart failure (RR 1.84; P < 0.00001). There was no significant relationship for developing myocardial infarction or for total cardiovascular diseases.

CONCLUSIONS

Our findings suggest that BAC was associated with an increased risk of cardiovascular mortality, and certain cardiovascular outcomes. There is thus a potential to use BAC as a sex-specific cardiovascular risk assessment tool. Furthermore, there is a need for more widespread reporting of BAC to better understand the pathophysiologic mechanisms behind its correlation with cardiovascular disease and to apply it in clinical practice.

Automated classification of fat-infiltrated axillary lymph nodes on screening mammograms

OBJECTIVE

Fat-infiltrated axillary lymph nodes (LNs) are unique sites for ectopic fat deposition. Early studies showed a strong correlation between fatty LNs and obesity-related diseases. Confirming this correlation requires large-scale studies, hindered by scarce labeled data. With the long-term goal of developing a rapid and generalizable tool to aid data labeling, we developed an automated deep learning (DL)-based pipeline to classify the status of fatty LNs on screening mammograms.

METHODS

Our internal data set included 886 mammograms from a tertiary academic medical institution, with a binary status of the fat-infiltrated LNs based on the size and morphology of the largest visible axillary LN. A two-stage DL model training and fine-tuning pipeline was developed to classify the fat-infiltrated LN status using the internal training and development data set. The model was evaluated on a held-out internal test set and a subset of the Digital Database for Screening Mammography.

RESULTS

Our model achieved 0.97 (95% CI: 0.94-0.99) accuracy and 1.00 (95% CI: 1.00-1.00) area under the receiver operator characteristic curve on 264 internal testing mammograms, and 0.82 (95% CI: 0.77-0.86) accuracy and 0.87 (95% CI: 0.82-0.91) area under the receiver operator characteristic curve on 70 external testing mammograms.

CONCLUSION

This study confirmed the feasibility of using a DL model for fat-infiltrated LN classification. The model provides a practical tool to identify fatty LNs on mammograms and to allow for future large-scale studies to evaluate the role of fatty LNs as an imaging biomarker of obesity-associated pathologies.

ADVANCES IN KNOWLEDGE

Our study is the first to classify fatty LNs using an automated DL approach.

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.

Detection and quantification of breast arterial calcifications on mammograms: a deep learning approach

OBJECTIVE

Breast arterial calcifications (BAC) are a sex-specific cardiovascular disease biomarker that might improve cardiovascular risk stratification in women. We implemented a deep convolutional neural network for automatic BAC detection and quantification.

METHODS

In this retrospective study, four readers labelled four-view mammograms as BAC positive (BAC+) or BAC negative (BAC-) at image level. Starting from a pretrained VGG16 model, we trained a convolutional neural network to discriminate BAC+ and BAC- mammograms. Accuracy, F1 score, and area under the receiver operating characteristic curve (AUC-ROC) were used to assess the diagnostic performance. Predictions of calcified areas were generated using the generalized gradient-weighted class activation mapping (Grad-CAM++) method, and their correlation with manual measurement of BAC length in a subset of cases was assessed using Spearman ρ.

RESULTS

A total 1493 women (198 BAC+) with a median age of 59 years (interquartile range 52-68) were included and partitioned in a training set of 410 cases (1640 views, 398 BAC+), validation set of 222 cases (888 views, 89 BAC+), and test set of 229 cases (916 views, 94 BAC+). The accuracy, F1 score, and AUC-ROC were 0.94, 0.86, and 0.98 in the training set; 0.96, 0.74, and 0.96 in the validation set; and 0.97, 0.80, and 0.95 in the test set, respectively. In 112 analyzed views, the Grad-CAM++ predictions displayed a strong correlation with BAC measured length (ρ = 0.88, p < 0.001).

CONCLUSION

Our model showed promising performances in BAC detection and in quantification of BAC burden, showing a strong correlation with manual measurements.

CLINICAL RELEVANCE STATEMENT

Integrating our model to clinical practice could improve BAC reporting without increasing clinical workload, facilitating large-scale studies on the impact of BAC as a biomarker of cardiovascular risk, raising awareness on women's cardiovascular health, and leveraging mammographic screening.

KEY POINTS

• We implemented a deep convolutional neural network (CNN) for BAC detection and quantification. • Our CNN had an area under the receiving operator curve of 0.95 for BAC detection in the test set composed of 916 views, 94 of which were BAC+ . • Furthermore, our CNN showed a strong correlation with manual BAC measurements (ρ = 0.88) in a set of 112 views.

Correlation Between Breast Arterial Calcifications and Higher Cardiovascular Risk: Awareness and Attitudes Amongst Canadian Radiologists Who Report Mammography

Background: Breast arterial calcification (BAC) on mammography correlates with increased cardiovascular risk. Reporting BAC is not standard practice. Our study evaluates the awareness of Canadian radiologists who report mammography of the clinical significance of BAC and their attitudes towards reporting BAC compared to their European and American counterparts. Methods: Following local institutional ethics approval, a 25 question survey (SurveyMonkey) was disseminated to Canadian radiologists via provincial and national society email lists. Responses were collected over 5 weeks (April-June 2022). Results: One hundred and eighty-six complete responses were collected. Sixty percent (112/186) were aware of the association between BAC and cardiovascular risk and 16% (29/186) document its presence in mammogram reports. Thirty five percent (65/186) occasionally document BAC if severe or in a young patient. Four percent (7/186) had local departmental guidelines on BAC reporting and 82% (153/186) agreed there is a need for national BAC reporting guidelines. Fewer Canadian radiologists were aware of the association between BAC and cardiovascular risk compared to European radiologists (60% vs 81%), report the presence of BAC compared to both European (15% vs 62%) and American (15% vs 35%) radiologists, and inform the patient of the presence of BAC compared to European radiologists (1% vs 46%). Conclusion: Canadian radiologists who report mammography were less aware of the association between BAC and cardiovascular risk than their European and American counterparts and were less likely to document the presence of BAC. Given the correlation of BAC with increased cardiovascular event risk, there is increased need for awareness as well as national BAC reporting guidelines.

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.

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.

Examining gain- and loss-framed messages in a novel breast cancer screening/cardiovascular context: Does framing matter?

Objective

Digital mammography can reveal not only breast cancer but also breast arterial calcification (BAC), which can indicate potential coronary artery disease. To explore ways to inform women of their BAC status in the context of a standard mammography results letter, we conducted a preliminary study comparing gain- and loss-framed messages to encourage follow-up cardiovascular care.

Methods

U.S. women over age 40 with no heart disease history (N = 227) were randomly assigned to view a mammography letter including BAC information in one of seven ways (three gain-framed messages, three loss-framed messages, one comparison message).

Results

Post-test measures indicated no significant differences on BAC knowledge, recall of test results and recommendations, perceived message effectiveness, or behavioral intentions for follow-up.

Conclusion

Despite showing no significant differences between message conditions, results supported the messages' ability to clearly convey BAC information and encourage intention for follow-up cardiovascular care.

Innovation

This experimental study represents the first published report examining the inclusion of BAC screening results within the mammography letter. It also explored the use of message framing in a dual detection-prevention context and suggests that future work should test the effects of including both framing tactics in messages designed to target dual-focus contexts.

Prevalence and Severity of Breast Arterial Calcification on Routine Mammography

Aim. To determine the frequency of detection and severity of breast arterial calcification (BAC) among women undergoing mammography on the basis of medical institutions in Moscow.Material and methods. The analysis included 4274 digital mammograms of women aged 40-93 who underwent preventive or diagnostic mammography. Standard full-format digital mammograms were performed in craniocaudal and mediolateral oblique projections. In addition to the standard diagnosis of breast disease, all mammograms were evaluated for the presence of BAC. The severity of BAC was assessed on a 12-point scale: mild 3-4 points, moderate 5-6 points, severe 7-12 points.Results. The average frequency of BAC was 10.1%, in the middle age group 50-59 years – 6.0%. The incidence of BAC increased with age, from 0.4% to 0.6% in women <50 years of age to >50% in women ≥80 years of age. A statistically significant and pronounced correlation was found between the woman's age and the presence of BAC r Pearson =0.769 (p<0.001). There was also a less noticeable but statistically significant correlation between age and severity of BAC r Spearman =0.319 (p<0.001). Regression analysis made it possible to estimate the probability of CAD depending on age. In women <50 years of age, only mild to moderate calcification occurred, while those ≥65 years of age had a significant increase in the incidence of severe CAD.Conclusion. There was an expected increase with age in both prevalence and severity of BAC. Cases of severe BAC in women younger than 65 years of age and any BAC in women younger than 50 years of age are atypical and require clarification of their association with cardiovascular and other diseases.

Breast Arterial Calcification Rates in a Diverse, Urban Group of Screening Mammography Patients

PURPOSE

Breast arterial calcifications (BAC), detected by digital mammography are a potential marker of coronary artery disease (CAD). Past BAC research has been limited by having primarily racially and ethnically homogeneous samples, samples at higher risk for CAD, and neglecting to explore the influence of women's health factors. The purpose of this study was to evaluate the prevalence of, and factors associated with, BAC in an ethnically and racially diverse group.

METHODS

We conducted a retrospective chart review on 17,237 screening mammography patients. Mammography results and patient responses to a demographic and medical history questionnaire were abstracted. Logistic regression was used.

RESULTS

BAC prevalence was 12.3%. Age was a significant risk factor, with the odds of BAC approximately doubling every decade. Age-adjusted analyses showed: 1) higher BAC prevalence among Hispanic, Black, and Ashkenazi women; 2) lower BAC prevalence among nulliparous and pre-menopausal women, those with dense breasts and breast implants, and those currently using HRT; and 3) no association between BAC prevalence and BMI or age at menarche.

CONCLUSIONS

BAC prevalence differs according to age, ethnicity, race, women's health, and breast-specific factors. Communication of BAC information in clinical settings could potentially prompt women to engage in preventive care.

Evaluation and Management of Blood Lipids Through a Woman's Life Cycle

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There are currently no sex-specific guidelines for evaluation and management of lipids.

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Lipids are impacted by normal hormonal changes in women throughout their life cycle.

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Management of lipids should incorporate sex-specific cardiovascular risk factors at each stage.

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Future objectives should focus on increasing women's presence in trials of lipid-lowering therapies.

There are currently no sex-specific guidelines for evaluation and management of blood lipids. While previous guidelines acknowledge sex-specific risk enhancing factors for lipid management in women for CVD prevention, this review focuses on how lipids are impacted during normal hormonal changes throughout a woman's life cycle- during adolescence, pre-pregnancy, pregnancy, pre- and perimenopause, menopause, and at older ages. In this review, the authors focus on management of primary prevention of CVD by examining sex-specific cardiovascular risk factors at each stage and pay special attention to statin use, statin side effects and non-statin therapies. Women need to understand their personalized cholesterol goals and ally with their clinicians to ensure successful management. Additionally, we highlight the biases that exist when treating dyslipidemia in women and the special care clinicians should take to ensure appropriate and aggressive therapies are made available to female patients. Finally, the authors recommend future research should focus on increasing enrollment of women in lipid trials. This is of paramount importance in discovering sex-specific difference in lipid management.

Reporting and Perceptions of Breast Arterial Calcification on Mammography: A Survey of ACR Radiologists

RATIONALE AND OBJECTIVES

The ACR Breast Commission conducted a member survey to evaluate current practices of reporting breast arterial calcification (BAC) on mammography and to determine perceptions about the value of BAC communication and follow-up recommendations among radiologists.

MATERIALS AND METHODS

In September 2020, an 18-item online survey was emailed to radiologist members of the American College of Radiology (ACR). Questions included radiologist demographics, current BAC reporting practices, follow-up recommendations, and perceptions about BAC. Five-point Likert scales were used and multivariate analysis was performed.

RESULTS

Of 598 completed survey responses, up to 87% (522/598) of ACR radiologist members include BAC in mammogram reports. However, only 41% (212/522) of respondents report BAC 'always' or 'most of the time'. Radiologist factors significantly associated with BAC reporting include years in practice and fellowship training with those in practice longer more likely to report BAC (OR 1.10, 95% CI, [1.01-1.20], p = 0.023) and those with fellowship training less likely to report BAC (OR 0.63, 95% CI, [0.42-0.94], p = 0.024). When BAC is reported, 69% (360/522) simply indicate the presence of BAC, 23% (121/522) provide a subjective grading of BAC burden, and 1% (6/522) calculate a BAC score. Among the radiologists reporting BAC, 58% (301/522) make no subsequent recommendations, while the remainder recommend primary care follow-up (39%; 204/522), cardiology evaluation (13%; 68/522), and/or coronary calcium scoring CT (11%; 59/522). Overall, there was agreement from 66% (392/598) of respondents that BAC is a cardiovascular risk factor. However, there was no consensus on whether patients and/or providers should be informed about BAC or whether reporting of BAC should become a standardized practice in breast imaging. Older and more experienced radiologists are more likely to agree that BAC is a cardiovascular risk factor (p = 0.022), providers should be informed about BAC (p = 0.002 and 0.006), BAC reporting should be a standardized practice (p = 0.004 and 0.001), and feel more comfortable informing patients about BAC (p = 0.001 and 0.003).

CONCLUSION

Radiologists' reporting practices and perceptions regarding BAC are not homogeneous. Although many radiologists report BAC to varying degrees, it is not routinely reported or recommended for follow-up in mammogram reports. Experienced radiologists are more likely to include and value BAC in their breast imaging practice.

Breast arterial calcifications as an indicator of atherosclerotic cardiovascular disease: comparative analysis of coronary computed tomography scoring systems and carotid intima-media thickness

BACKGROUND

Breast arterial calcification (BAC) is easily detected and commonly observed on screening mammography. That is more frequent among people with diabetes, and these people are at risk of coronary artery disease. The incidence of BAC increases with advancing age. We aimed to determine whether BAC detected by mammography is associated with the development of coronary atherosclerosis in asymptomatic women. It can help reduce morbidity and mortality secondary to atherosclerotic cardiovascular disease.

METHODS

We included one hundred and eighty women over the age of 40 who underwent mammography screening in this multi-modality study. Mammography evaluated the presence of calcifications, the number of involved arteries, and the distribution. We questioned the patients about cardiovascular risk factors such as hypertension and diabetes. The coronary artery disease severity was assessed according to both Agatston and calcium scores on coronary computed tomography (CT). Besides, the relationship between these scores and correlation with carotid artery intima-media thickness was investigated. We stated mean and standard deviation (SD) for continuous variables and reported frequency distributions and percentages. SPSS software version 25.0 was used to perform the analysis.

RESULTS

Overall, 302 of 3,600 cases were positive for BAC. However, 120 of them could be included in the study by the eligibility criteria of our research. In univariate analysis, age, hyperlipidemia, DM, HT, and smoking history were risk factors that significantly affected BAC development. The impact of age and diabetes were maintained in the logistic regression analysis (P<0.005), while the significant effect of the other variables was vanished (P>0.02). Furthermore, moderate and high BAC scores were correlated with higher coronary atherosclerosis scores.

CONCLUSIONS

BAC may predict an additional risk factor for coronary artery disease, particularly in patients having higher scores. That may be an accurate indicator for subsequent development of coronary arterial calcifications so that it may be possible to reduce morbidity and mortality associated with coronary atherosclerosis.

Breast Arterial Calcifications: Reporting Preferences and Impact on Screening for Coronary Artery Disease

OBJECTIVE

Breast arterial calcifications (BAC) have been shown to correlate with measures of coronary artery disease risk stratification, although reporting of BAC is optional by BI-RADS guidelines. The purpose of this study is to determine referring provider preferences in BAC reporting on mammography reports and if such reporting has any impact on patient management.

METHODS

This study was approved by the local institutional review board. A voluntary eight-question survey regarding the preferences and outcomes of BAC reporting on mammography was distributed to 1085 primary care physicians, obstetrics and gynecologists, medical oncologists, and breast and general surgeons in our health system via a secure online platform. Data analysis including Pearson chi-square was performed with a P-value of <0.05 for significance.

RESULTS

A response rate of 19.1% (207/1085) was attained, with 21/207 (10.1%) of respondents indicating they do not routinely order mammograms excluded from further analysis. A total of 62.4% (116/186) of ordering physicians indicated a preference for reporting of BAC in both the body and impression of the radiology report, with 82.3% (153/186) of respondents placing importance on the quantity of atherosclerotic calcifications. Most participants (148/186, 79.6%) reported that the presence of BAC would prompt further investigation for coronary artery disease and associated risk factors.

CONCLUSION

The majority of responding physicians indicated a preference for detailed reporting of BAC and that such reporting would impact patient care. Understanding referring provider preferences regarding ancillary findings of BAC will allow for improved communication and value in mammography.

Assessing the Stress Echocardiography in Women With Breast Arterial Calcification

Objective: breast arterial calcification (BAC) is one of the most prevalent mammographic findings and has been debated as a marker of cardiovascular disease (CVDs). The present study aimed to assess the findings of stress echo in women with BAC. Materials and methods: This cross-sectional study was conducted on women who undergo mammography for routine breast cancer screening at Imam Reza hospital, western Iran from March 2018 to July 2018. The patients underwent stress echocardiography to evaluate the probability of myocardial ischemia (MI). Chi-square and independent t-tests were used to assess the differences between subgroups. Results: BAC was present in 61 (15.2%) women. The mean age of the patients with BAC was significantly higher than the patients without BAC (58.59± 7.82 vs. 55.32±6.57, p =0.003). Prevalence rates of the menopause (88.5% vs. 71.1%, p=0.009), hypertension (29.5% vs. 17.7%, p=0.032), and hypercholesterolemia (24.6% vs. 13.0, p=0.018) were significantly higher in the patients with BAC compared to the patients without BAC. The prevalence rate of MI symptoms in the patients with BAC was equal to 24.6%. Significantly, more women with BAC were positive for myocardial ischemia compared to the women without BAC (24.6% vs. 8.5%, p<0.001). The prevalence rates of the diabetes mellitus, hypertension, hypercholesterolemia, and history of CVDs were significantly higher in the patients who were positive for MI. Conclusion: It was found that BACs are correlated with an increased occurrence rate of CVDs. Our results illustrated that the patients who were positive for MI were more plausible to be diabetic, hyperlipidemic, hypertensive, and having a history of CVDs.

Semiquantitative score of breast arterial calcifications on mammography (BAC-SS): intra- and inter-reader reproducibility

Background

Breast arterial calcifications (BAC), representing Mönckeberg's sclerosis of the tunica media of breast arteries, are an imaging biomarker for cardiovascular risk stratification in the female population. Our aim was to estimate the intra- and inter-reader reproducibility of a semiquantitative score for BAC assessment (BAC-SS).

Methods

Consecutive women who underwent screening mammography at our center from January 1^st to January 31^st, 2018 were retrieved and included according to BAC presence. Two readers (R1 and R2) independently applied the BAC-SS to medio-lateral oblique views, obtaining a BAC score by summing: (I) number of calcified vessels (from 0 to n); (II) vessel opacification, i.e., the degree of artery coverage by calcium bright pixels (0 or 1); and (III) length class of calcified vessels (from 0 to 4). R1 repeated the assessment 2 weeks later. Scoring time was recorded. Cohen's κ statistics and Bland-Altman analysis were used.

Results

Among 408 women, 57 (14%) had BAC; 114 medio-lateral oblique views were assessed. Median BAC score was 4 [interquartile range (IQR): 3-6] for R1 and 4 (IQR: 2-6) for R2 (P=0.417) while median scoring time was 156 s (IQR: 99-314 s) for R1 and 191 s (IQR: 137-292 s) for R2 (P=0.743). Bland-Altman analysis showed a 77% intra-reader reproducibility [bias: 0.193, coefficient of repeatability (CoR): 0.955] and a 64% inter-reader reproducibility (bias: 0.211, CoR: 1.516). Cohen's κ for BAC presence was 0.968 for intra-reader agreement and 0.937 for inter-reader agreement.

Conclusions

Our BAC-SS has a good intra- and inter-reader reproducibility, within acceptable scoring times. A large-scale study is warranted to test its ability to stratify cardiovascular risk in women.

Breast Arterial Calcification: A Potential Biomarker for Atherosclerotic Cardiovascular Disease Risk?

PURPOSE OF REVIEW

We aimed to summarize the current evidence regarding the association between breast arterial calcification (BAC) and atherosclerotic cardiovascular disease (ASCVD) in women and discuss the potential role of BAC in the risk stratification and preventive approaches for ASCVD.

RECENT FINDINGS

BAC has emerged as a potential women-specific risk marker for ASCVD. Although BAC presents as a medial calcification of the arteries, notably different from the intimal atherosclerotic process, current evidence supports a correlation between BAC and ASCVD risk factors or subclinical and clinical ASCVD, such as coronary artery disease or stroke. As millions of women undergo mammograms each year, the potential clinical application of BAC in enhanced ASCVD risk estimation, with no additional cost or radiation, has tremendous appeal. Although further research regarding optimal risk assessment and management in women with BAC is required, the presence of BAC should prompt healthy cardiovascular lifestyle modifications.

Systemic diseases affecting the breast: Imaging, diagnosis, and management

Various systemic diseases of benign or malignant etiologies can clinically manifest in the breast. Some imaging findings of breast lesions can be pathognomonic for a given condition, while others are non-specific, mimicking primary breast carcinoma and requiring tissue biopsy for definitive diagnosis. In addition to obtaining a detailed clinical history, radiologists should be familiar with the diverse clinical and imaging characteristics of these conditions to help exclude primary breast cancer and avoid unnecessary interventions. This review aims to discuss the clinical presentations, imaging features, pathologic findings, and management of systemic conditions that may affect the breast.

Microvascular Disease and Small-Vessel Disease: The Nexus of Multiple Diseases of Women

Microvascular disease, or small-vessel disease, is a multisystem disorder with a common pathophysiological basis that differentially affects various organs in some patients. The prevalence of small-vessel disease in the heart has been found to be higher in women compared with men. Additionally, other diseases prominently affecting women, including heart failure with preserved ejection fraction, Takotsubo cardiomyopathy, cerebral small-vessel disease, preeclampsia, pulmonary arterial hypertension (PAH), endothelial dysfunction in diabetes, diabetic cardiomyopathy, rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis, may have a common etiologic linkage related to microvascular disease. To the best of our knowledge this is the first article to investigate this potential linkage. We sought to identify various diseases with a shared pathophysiology involving microvascular/endothelial dysfunction that primarily affect women, and their potential implications for disease management. Advanced imaging technologies, such as magnetic resonance imaging and positron-emission tomography, enable the detection and increased understanding of microvascular dysfunction in various diseases. Therapies that improve endothelial function, such as those used in PAH, may also be associated with benefits across the full spectrum of microvascular dysfunction. A shared pathology across multiple organ systems highlights the need for a collaborative, multidisciplinary approach among medical subspecialty practitioners who care for women with small-vessel disease. Such an approach may lead to accelerated research in diseases that affect women and their quality of life.

Breast Arterial Calcification is Associated with the Progression of Coronary Atherosclerosis in Asymptomatic Women: A Preliminary Retrospective Cohort Study

We evaluated whether breast arterial calcification (BAC) is associated with the progression of coronary atherosclerosis in asymptomatic women. This retrospective observational cohort study analysed asymptomatic women from the BBC registry. In 126 consecutive women (age, 54.5 ± 7.0 years) who underwent BAC evaluation and repeated coronary computed tomography angiography (CCTA) examinations, the coronary arterial calcification score (CACS) and segment stenosis score (SSS) were evaluated to assess the progression of coronary arterial calcification (CAC) and coronary atherosclerotic plaque (CAP). CAC and CAP progression were observed in 42 (33.3%) and 26 (20.6%) women, respectively (median interscan time, 4.3 years), and were associated with the presence of BAC and a higher BAC score at baseline. Women with BAC demonstrated higher CAC and CAP progression rates and showed higher chances for CAC and CAP progression during follow-up (p < 0.001 for both). In multivariable analyses, the BAC score remained independently associated with both CAC and CAP progression rates after adjustment for clinical risk factors (β = 0.087, p = 0.029; and β = 0.020, p = 0.010, respectively) and with additional adjustment for baseline CACS (β = 0.080, p = 0.040; and β = 0.019, p = 0.012, respectively) or SSS (β = 0.079, p = 0.034; and β = 0.019, p = 0.011, respectively). Thus, BAC may be related to the progression of coronary atherosclerosis and its evaluation may facilitate decision-making.

Mammographic Screening as a Tool for Cardiovascular Risk Assessing. Part 2. Association of Breast Arterial Calcification and Cardiovascular Diseases

Prospects for the use of mammographic detection of breast arterial calcification (BAC) to improve the stratification of cardiovascular risk in the female population are of increasing interest. The purpose of the 2 part of the review is the analysis of modern literature on the relationship of the BAC with the prevalence and mortality from cardiovascular diseases (CVD). The presence of BAC on mammograms is associated with a higher likelihood of myocardial infarction, death from coronary heart disease (CHD) and CVD, as well as a 3.5-fold increase in the risk of CHD and a 5-year coronary incident (p=0.003). Women with BAC have a higher likelihood of coronary artery disease detected during angiography than women without BAC (p<0.001). Severe BAC has a stronger association with CVD than mild calcification. The association of BAC with cerebrovascular diseases and a 1.4-fold increase in the risk of ischemic stroke (p=0.004), atheromatosis of the carotid arteries and an increase in the thickness of the intima-media complex is shown. BAC is associated with atherosclerotic lesions of peripheral arteries and a decrease in the ankle-brachial index <0.9 (p=0.048). In women with chronic kidney disease, the presence of BAC indicates a 4.5-fold increase in the risk of complications associated with impaired blood flow in peripheral arteries. It is shown that the addition of BAC to the generally accepted (standard) vascular risk assessment algorithms Framingham Risk Score and Pooled Cohort Equation significantly increases the accuracy of prediction of CHD (p=0.02 and p=0.010, respectively). The detection of BAC on mammographic screening is a new promising direction for cardiovascular prophylaxis in women and opens up new opportunities for identifying groups of people with subclinical forms of CVD and high cardiovascular risk.