On Oct. 1, a first-of-its-kind law went into effect in Maryland that requires mammography centers to notify patients if their scans show evidence of breast arterial calcification (BAC) — calcium deposits within breast arteries that have been linked to an elevated risk for heart disease.
These calcium-laden arteries have always appeared on mammograms — but they’ve long been considered an incidental finding of little, if any, significance, said Matthew Nudy, a general cardiologist and assistant professor of medicine and public health sciences at the Penn State College of Medicine. There’s no known tie between BAC and breast cancer, and some of the early research on BAC and cardiovascular disease was inconclusive, he explained.
But as larger studies using artificial intelligence have clearly linked BAC to increased risk for cardiovascular events such as heart failure, heart attack and stroke, some mammography centers have begun to include BAC on mammogram reports. Others use Food and Drug Administration-cleared AI software to localize, flag and sometimes even quantify the extent of BAC present on a mammogram image, though this is often an add-on service with an out-of-pocket fee.
The Maryland law makes it the first state to mandate notification of BAC — whether it’s present or absent — on all routine mammograms at no additional cost. Experts suspect BAC notification will follow a similar trajectory as breast-density reporting, which started with state-level legislation and became a national requirement in 2023.
“I’m so glad Maryland jumped in and made the first move [for BAC reporting], and I suspect [other states] are going to follow suit,” said Tahira Ahmed, a breast radiologist and medical director of breast imaging for the Maryland imaging network of RadNet, an outpatient imaging service provider.
Offering women insight into their cardiovascular risk right in their mammogram report has the potential to help close the pervasive gender gap in diagnosis and treatment of heart disease.
Surveys consistently show that women underestimate the threat of heart disease, which is their No. 1 killer, mistakenly believing that breast cancer poses a bigger risk, Nudy said. So, women may be more likely to show up for a mammogram than to get screened for cardiovascular disease, for instance with blood pressure and cholesterol monitoring. Incorporating BAC into mammogram results turns the test into a twofer: Women who are already undergoing screening for breast cancer can learn about their cardiovascular risk, too.
Read on to learn about the connection between BAC and cardiovascular health, plus what steps to take if you get a positive BAC result.
The link between breast arterial calcification and heart disease
Breast arterial calcification is a bit different from coronary artery calcification (CAC), which has long been linked to a higher risk of heart disease. The latter is the result of atherosclerosis, or buildup of a sticky substance called plaque inside the arteries leading to the heart, which narrows them and limits blood flow. In BAC, the calcium deposits occur in a deeper layer of the arteries in the breasts, causing them to become stiff, Nudy explained.
Breast arteries that aren’t as pliable can’t expand as easily to transport blood, which research suggests may lead to high blood pressure and, ultimately, poorer blood flow back to the heart.
At the same time, BAC is linked to calcification in other arteries throughout the body, including CAC, Ahmed noted, “which suggests that if someone is starting to show disease in the breast, then there’s a good chance that they’re experiencing disease in the coronary arteries as well.” BAC is also associated with traditional cardiovascular risk factors such as older age, high blood pressure, poor cholesterol markers, diabetes and menopausal status.
“We hypothesize that breast arterial calcification is a result of cardiovascular risk factors being present for some time and causing stress on the cardiovascular system,” Nudy said. So it may serve as a sign of well-established underlying risk factors.
Nudy was also a co-author of a recent study showing that the more severe BAC that participants had relative to their age, the more likely they were than their peers to have a poor cardiac outcome (such as a stroke or heart failure) within a roughly five-year period.
While the new Maryland law only requires reporting a simple “yes” or “no” for the presence of BAC — not its extent or severity — Nudy and Ahmed suspect that future iterations of state and federal laws could mandate reporting the grade of BAC, too, particularly as AI tools for automatically quantifying BAC become increasingly available.
What to do if your mammogram results show breast arterial calcification
Experts are still determining the best way to act on a BAC finding. We don’t yet have a randomized clinical trial showing that any specific intervention leads to a “meaningful reduction in cardiovascular disease,” Nudy said. (Though more answers may be on the horizon, Nudy said, pointing to an Australian clinical trial that will investigate whether a nurse-led risk-reduction program in women with BAC might lower the burden of plaque in their heart arteries.)
But both Nudy and Ahmed said evidence of BAC on a mammogram should prompt you to talk to your doctor about your personal cardiovascular risk.
Recent guidelines from the American Heart Association advise clinicians to use a risk assessment tool called the PREVENT calculator — which determines 10-year and 30-year risk of a heart event based on factors such as sex, age, blood pressure and cholesterol — in all patients ages 30 to 79. A BAC finding is an extra nudge to ask your primary care doctor about PREVENT, Ahmed and Nudy said. If you’ve had a physical in the past year, you can also plug your details into the online version of PREVENT and discuss the results with your doctor.
They can help you weigh the BAC finding in light of your PREVENT score and possibly other factors tied to heart health (e.g., a family history of heart disease or pregnancy-related conditions such as preeclampsia) to get a sense of where your risk truly falls. If it’s elevated, they may recommend starting a statin to reduce your risk, Nudy said.
BAC can also be a reminder to double down on lifestyle habits for heart health such as increasing your physical activity, eating a plant-forward diet and getting ample sleep.
Ultimately, the biggest benefit of BAC reporting in mammogram results is to flag those women who may have had no idea about their possibly higher risk for a heart problem — whether because they’re young or simply hadn’t seen their doctor to be evaluated in a while, Ahmed said: “This notification might be the first indication that they should have a talk with their doctor and perhaps make some lifestyle changes to get on top of their risk.”
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