Breast arterial calcification on mammography predicts higher cardiovascular event risk in women

Breast arterial calcification (BAC) is commonly observed on screening mammography and may provide a low-cost opportunistic marker to enhance cardiovascular risk assessment in women, in whom cardiometabolic risk is often underrecognized by traditional scores. We performed a PRISMA-guided systematic review and meta-analysis of PubMed, Embase, Scopus, and ClinicalTrials.gov through April 30, 2025, to evaluate the association between BAC and both future cardiovascular events and underlying coronary pathology. Cohort studies reporting adjusted hazard ratios (HRs) for incident cardiovascular events were pooled using random-effects meta-analysis, with prespecified subgroup analyses by BAC ascertainment method and study design, while additional studies reporting odds ratios (ORs) for coronary artery disease (CAD) or coronary artery calcium (CAC) were synthesized separately. Four cohort studies, including approximately 25,000 women with 6 to 12 years of follow-up demonstrated that BAC was associated with significantly higher incident cardiovascular events (pooled HR 1.82, 95% CI 1.37 to 2.43; p <0.001), with the strongest association observed for radiologist-reported BAC and concordant findings across artificial intelligence-derived and densitometric measures, and no evidence of small-study effects. Across OR-based analyses including approximately 5,000 women, BAC was strongly associated with underlying coronary pathology, with a pooled adjusted OR of 4.00 (95% CI 2.44 to 6.56) for CAD and similarly elevated odds for CAC. In conclusion, BAC detected on routine mammography identifies women at substantially higher future cardiovascular risk and is strongly associated with subclinical coronary disease, supporting its potential role as a scalable, no-added-cost marker to enhance cardiovascular risk assessment in women.