Breast arterial calcification as a cardiovascular risk biomarker: A multicenter analysis of Indian women

Background: Breast arterial calcification (BAC) visible on routine screening mammography is emerging as a potential marker for cardiovascular disease (CVD) risk in women. This study pooled data from three institutional cohorts in India to evaluate the association between BAC, angiographically confirmed coronary artery disease (CAD), and survival outcomes. Materials and Methods: We retrospectively analyzed mammograms from three cohorts: a screening population (2020–2021, n = 335), a breast cancer cohort (2013–2017), and a mixed screening/diagnostic group (2019–2023). BAC was graded (0–3) as per the Canadian Society of Breast Imaging criteria. Primary endpoints included obstructive CAD (≥50% stenosis) and all-cause mortality. Multivariable logistic regression and Cox models were adjusted for traditional risk factors (age, diabetes, hypertension, and dyslipidemia). Results: BAC prevalence in the screening cohort was 11.3%. Obstructive CAD was significantly more frequent in BAC-positive women (83.9%) compared to BAC-negative (4.0%), with an adjusted odds ratio of 32.1 (95% confidence interval: 11.4–90.8; P < 0.001). In the breast cancer cohort, BAC-positive women had a significantly lower median survival (28.6 vs. 43.6 months; hazard ratio = 1.92, P = 0.02). These findings were consistent across all cohorts. Conclusions: BAC independently predicts obstructive CAD and poorer survival among Indian women, beyond traditional risk factors. Routine BAC reporting in mammography and integrated cardio-oncology referrals may enhance cost-effective CVD risk stratification in India.