Breast Arterial Calcification as a Predictor for Future Cardiovascular Events and Mortality: A Systematic Review and Meta-analysis

Clinical Snapshot

Key Findings

• P Value: P<0.0001

• Effect Size: 32% increased risk of all-cause mortality with BAC presence

• Primary Outcome: All-cause mortality HR 1.32 (95% CI 1.20-1.45, P<0.0001)

• Nnt Or Sensitivity: Hazard ratios consistent across cardiovascular outcomes (1.2-1.48 range)

• Confidence Interval: 95% CI 1.20-1.45

Clinical Application

Highly feasible - BAC visible on routine mammograms without additional radiation or cost Directly applicable to BreastScreen Australia program; could inform cardiovascular risk stratification without additional imaging costs or TGA approval requirements Women aged 50-74 years attending BreastScreen Australia mammography screening

Abstract

OBJECTIVE: Breast arterial calcification (BAC) is a surrogate marker of cardiovascular disease (CVD); however, its associations with incident mortality and major adverse cardiovascular events (MACEs) have not been systematically evaluated. The association between BAC and incident MACE and whether this is influenced by the method of BAC assessment was examined. METHODS: PubMed, MEDLINE, and EMBASE were reviewed to June 2025 for studies comparing BAC status with incident MACE (composite of death, myocardial infarction [MI], stroke, heart failure). The primary outcome was all-cause mortality. Random-effects meta-analysis was performed using hazard ratios (HRs) with 95% CIs. Subgroup analysis was conducted by method of BAC measurement and restricted to screening mammography cohorts, PROSPERO registration (CRD42020202612). RESULTS: Of 1118 studies screened, 24 were included (236 475 participants; mean age 58.5 years). Breast arterial calcification presence associated with all-cause mortality (HR, 1.32; 95% CI, 1.20-1.45; P <.0001) (follow-up 0.55-26 years). Increased risk was observed for cardiovascular mortality (HR, 1.38; 95% CI, 1.14-1.66; P = .0009), heart failure (HR, 1.29; 95% CI, 1.20-1.37; P <.0001), stroke (HR, 1.2; 95% CI, 1.11-1.30; P <.0001), and MI (HR, 1.2; 95% CI, 1.15-1.26; P <.0001). When restricted to screening mammography cohorts without concurrent indications for cardiovascular investigation (5 studies, n = 85 647), associations remained significant for all-cause mortality (HR, 1.34; 95% CI, 1.14-1.58; P = .0004), cardiovascular mortality (HR, 1.38; 95% CI, 1.14-1.66; P = .0009), heart failure (HR, 1.48; 95% CI, 1.19-1.86; P = .0005), and stroke (HR, 1.34; 95% CI, 1.08-1.67; P = .008). Associations with incident outcomes were observed only in studies using quantitative BAC assessment (HR, 1.31; 95% CI, 1.19-1.44; P = .002). CONCLUSION: Breast arterial calcification is a promising prognostic marker of mortality and CVD risk. Recognition of this incidental finding may enable timely identification of at-risk individuals.

References

1. 1.Nandurkar, R., Vasanthakumar, S., Stewart, J., Aldous, E., Tu, H., Goel, V., Scanlon, L., Patel, A., Soh, C., & Nerlekar, N. (2026). Breast arterial calcification as a predictor for future cardiovascular events and mortality: A systematic review and meta-analysis. Journal of Breast Imaging. https://doi.org/10.1093/jbi/wbaf087