Cardiovascular disease remains the leading cause of death among women globally and carries significant mortality and poorer outcomes compared with men. Traditional cardiovascular risk assessment methods are less accurate in women partly because female-specific risk factors are less studied and often absent from standard models. Mammography is primarily used for breast cancer screening, but images can also contain information on breast arterial calcifications. These findings have associations with coronary artery calcium scores and increased cardiovascular risk. Despite this potential, breast arterial calcifications are not routinely reported in clinical practice, largely because reporting practices vary and standardised follow-up guidance remains absent. A recent educational review published in the Journal of Breast Imaging examines breast arterial calcifications as a potential marker for cardiovascular risk in women.
Breast Arterial Calcifications as a Risk Marker
Breast arterial calcification is a form of medial arterial calcification. It appears on mammograms as round or tram-track calcifications in vessel walls. It differs from intimal arterial calcification, which relates to atherosclerotic plaque burden and may narrow the arterial lumen. Medial arterial calcification involves circumferential thickening of the vessel in a non-occlusive manner and contributes to stiffer, less compliant vessels.
Medial arterial calcification mainly affects muscular arteries and has been associated with diabetes mellitus, chronic kidney disease and ageing. Its impact relates more to arterial stiffening and related haemodynamic changes than to direct lumen narrowing. Breast arterial calcifications have appeared in a wide range of women undergoing mammography, with variation linked to the populations and comorbidities examined.
Mammogram images can therefore provide information beyond breast cancer detection. Breast arterial calcifications correlate with coronary artery calcium score, and greater BAC severity aligns with higher risk of asymptomatic coronary artery disease. Breast adipose tissue composition and total breast volume also appear as potential imaging biomarkers for cardiometabolic risk, although these features are not routinely assessed or included in mammography reports. Current practice leaves potentially relevant cardiovascular information outside routine communication pathways.
Classification Methods Remain Inconsistent
No standardised recommendation or mandated requirement currently governs the reporting of BAC presence or severity. Classification methods range from simple present-or-absent reporting to subjective grades, multi-point scores, semiquantitative approaches and artificial intelligence-enabled quantification. In the United States, radiologists who report BAC most often note only its presence or absence. Smaller proportions provide qualitative or quantitative assessment, and formal scoring remains uncommon.
Several subjective grading systems classify BAC through binary, ordinal or multi-level categories. One 0–3 scale separates no calcifications, scattered punctate or short linear calcifications, more abundant calcifications and continuous circumferential calcifications. The distinction between limited and more abundant disease creates scope for inter-reader variability.
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The Canadian Society of Breast Imaging has advocated a four-point grading system with reporting language and follow-up recommendations. The system classifies grade 0 as no arterial calcifications, grade 1 as mild punctate calcifications without tram-track or ring calcifications, grade 2 as moderate coarse or tram-track calcifications in fewer than three vessels and grade 3 as severe involvement of three or more vessels. The Society recommends reporting severe BAC for all patients and reporting any BAC grade for patients younger than 55.
More detailed systems include a 12-point BAC score based on the number of involved vessels, the length of calcified segments and calcium density. A semiquantitative BAC score combines vessel number, opacity and calcified length. These approaches provide greater structure, but calculation complexity limits routine clinical use.
AI May Support Automated Quantification
Manual BAC quantification can be difficult because calcifications vary in appearance and extent. Automated detection and quantification could reduce additional workload for radiologists while supporting broader use of BAC as a cardiovascular risk biomarker. Artificial intelligence models under development aim to identify and classify BAC on mammograms, including full-field digital mammography and digital breast tomosynthesis images.
Automated and AI-enhanced tools can segment, quantify and report BAC through radiology reports, patient portals or text messages. Hybrid models have also been suggested, combining mammographic BAC with cardiovascular risk factors and medication data from electronic medical records. These approaches could help tailor follow-up recommendations to patients who may benefit most from BAC reporting and preventive risk assessment.
Validation data for an FDA-cleared AI-based detection solution showed strong performance for full-field digital mammography and digital breast tomosynthesis. A large retrospective assessment using the same model linked both BAC presence and quantity with mortality and cardiovascular outcomes after adjustment for established risk factors. Automated systems still face limitations. False positives can arise from round calcifications within skin folds or Cooper’s ligaments, while false negatives can occur in dense breasts or very faint BAC.
Cost remains another barrier. Screening mammography may be covered by insurance, but standalone AI tools for BAC assessment may not be covered. Economic evaluation of direct and downstream costs remains necessary to clarify the cost-effectiveness of these technologies.
Breast arterial calcification reporting offers a possible route for communicating cardiovascular risk information already visible on mammography. Current practice remains uneven, with no universal reporting standard, limited follow-up guidance and differing views among patients, radiologists and referring clinicians. Patients generally favour receiving BAC information, while radiologists and clinicians vary in awareness, reporting preferences and follow-up approaches. Clearer terminology, practical reporting systems, education and coordinated pathways between breast imaging, primary care and cardiology remain central to more consistent use of BAC in women’s cardiovascular risk assessment.
Source: Journal of Breast Imaging
Image Credit: iStock
References:
Stephens K, McLin RK, Ismail RT et al. (2026) Classification and Reporting of Breast Arterial Calcifications: Current State and Ongoing Challenges. Journal of Breast Imaging, 8(2):125–135.
