Breast Imaging in Focus: What New Multicenter Research Reveals About Breast Arterial Calcification on Mammography

Breast arterial calcification (BAC) has traditionally been viewed as an incidental finding on mammography.However, this perception is changing rapidly. BAC is a form of medial arterial calcification visible on mammography and growing evidence demonstrates that BAC is associated with cardiovascular disease, including ischemic heart disease, stroke, heart failure and mortality.

This clinical development is particularly important because Maryland recently become the first state to pass legislation requiring patient notification when BAC is identified on mammography. This law will take effect on October 1, 2026.

A recent article published in JACC: Cardiovascular Imaging is especially timely because the study addresses an important question: Can BAC quantification meaningfully improve cardiovascular risk prediction?¹

The authors performed a multicenter retrospective cohort study of 21,514 women aged 40 years or older, without known cardiovascular disease, who underwent screening mammography and atherosclerotic cardiovascular disease (ASCVD) risk assessment.¹ Breast arterial calcification was quantified using an AI based tool and expressed as an age-adjusted percentile. The primary outcome was major adverse cardiovascular events (MACE), including death, ischemic heart disease, stroke and heart failure. The age adjustment is important because BAC increases with age. As a result, the same raw BAC score may have very different clinical significance in a 45-year-old woman compared with a 75-year-old woman.

The authors therefore developed an age-adjusted BAC percentile nomogram analogous to age-based coronary artery policy and percentiles used in cardiovascular imaging.

For radiologists, this approach may eventually make BAC reporting more clinically meaningful and easier to communicate to referring physicians and patients.

Breast arterial calcification was identified in 22.7 percent of women and increased with age from 8 percent in women younger than 50 years to 61 percent in women older than 70 years. During a mean follow-up period of 4.7 years, 828 major adverse cardiovascular events occurred. Each 10 percentile increase in BAC was associated with increased risk of MACE independent of conventional cardiovascular risk factors.¹

Importantly, the addition of BAC to a conventional risk assessment model improved cardiovascular risk prediction. The C statistic increased from .67 to .71 and BAC improved risk reclassification, particularly among women categorized as low or intermediate risk by conventional risk assessment models.¹

For breast imaging radiologists, the clinical implications of these findings are practical.

• Breast arterial calcification should no longer be regarded as merely an incidental mammography finding.

• Automated BAC quantification may help reduce workflow burden and facilitate standardized reporting practices.

• BAC reporting may become increasingly relevant as legislation and patient notification requirements expand beyond Maryland.

At the same time, careful communication remains important. The authors emphasize that formal guideline directed management thresholds for BAC have not yet been established for radiologists, and especially breast imaging radiologists, the challenge moving forward will be to report BAC in a manner that is standardized, clinically responsible and useful for downstream cardiovascular risk assessment.

Dr. Bahl is an associate professor at Harvard Medical School and a breast radiologist affiliated with Massachusetts General Hospital.

Reference

1. Nerlekar N, Soh CH, Vasanthakumar S, et al. A novel breast arterial calcification age-based percentile nomogram for the incremental prediction of incidental cardiovascular events. JACC Cardiovasc Imaging. 2026 Apr 24:S1936-878X(26)00152-X. doi: 10.1016/j.jcmg.2026.03.008. Online ahead of print.