Correspondence Breast arterial calcifications on mammography and coronary artery disease: A new screening tool for cardiovascular disease? Marco Zuin a,d , Gianluca Rigatelli b , Fiorenzo Scaranello c , Sergio Giuseppe Ribecco c , Claudio Picariello a , Giovanni Zuliani d , Giuseppe Faggian e , Pietro Zonzin a , Loris Roncon a, ⁎ a Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy b Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy c Department of Radiology, Santa Maria della Misericordia Hospital Rovigo, Italy d Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy e Department of Cardiac Surgery, University of Verona, Italy article info Article history: Received 25 April 2016 Accepted 27 June 2016 Available online 28 June 2016 Keywords: Breast arterial calcifications Coronary artery disease Cardiovascular disease To the editor: Cardiovascular disease and breast cancer are two important causes of mortality in women [1]. Despite that the American Cancer Society currently recommends annual mammographic screening for all woman aged 40 years or older for early detection of breast cancer [2], no routine screening for coronary artery disease (CAD) is actually per- formed or recommended in the general population. In the past years, several prospective and cross-sectional studies have demonstrated that important information about the presence and severity of subclin- ical atherosclerosis and cardiovascular disease (CVD) could be assessed by mammograms (MM) [3,4]. However, the presence or absence of breast arterial calcification (BAC) is often ignored during the mammo- graphic assessment. The presence of coronary artery calcium (CAC) is a well-established risk factor for CAD; moreover, abnormal calcification in other vascular beds has been related with increased risk of CAD in asymptomatic patients. Recently, many investigations have demon- strated that BAC is a potential women-specific risk factor for both CVD and CAD [5]. In fact, the presence of BAC on screening MM have been described by Matsumura and coll. as a strong and independent predictor of coronary artery calcifications [6]. Previous reports indicate that up to 20% of all coronary artery events occur in the absence of tra- ditional risk factors. Besides, BAC has already been associated with arte- rial hypertension, diabetes, dyslipidaemia and renal failure [7]. Also pre- existing CAD has been related to higher prevalence of BAC detected by MM [8]. In the past years, different non-invasive imaging techniques have been evaluated to identify women at high-cardiovascular risk. Different studies have linked the presence of coronary artery calcium (CAC), detected at coronary CT angiography, with BAC [7]. However, also the association between BAC (seen on mammography) and CAD (detected at coronary angiography) has been described in recent med- ical literature (Fig. 1). These evidences raise an important question: “Could mammography be used as a screening tool in CVD and especially in women with suspected CAD? BAC appears to be associated with an increased risk of CVD events while it has been linked only with some of the traditional cardiovascular risk factors as age, body mass index (BMI), diabetes, hypertension, albuminuria, homocysteine and triglyc- erides [3,4,7]. Moreover, BAC seems to be to be related with previous pregnancy and lactation [9]. On the contrary an inverse association with smoke and menopausal hormone therapy was reported [7]. From a pathological point of view, it is important to consider that the location of BAC and CAC are different. Indeed, BAC is a manifestation of Mönckeberg's arteriosclerosis, which has a medial location in the artery wall and occurs in the absence of macrophages or lipid deposits. On the contrary, CAC has an intimal location and is associated with expression of growth factors, inflammatory cells, lipid deposits and matrix proteins. In this setting, BAC could be considered as a non- obstructive condition leading to a reduced arterial compliance [1]. In a recent review, a total of 35,542 patients were enrolled across 25 studies evaluating the association between BAC and CAD, CVD, stroke, cerebral artery disease, CAC, and carotid and peripheral artery diseases. Several previous studies showed a statistically significant relation between BAC and presence of CAD, CVD and associated mortality. Moreover, the presence of BAC was predictive of cerebral, carotid, and peripheral artery disease [3]. In a more recent meta-analysis, Hendriks and coll. reported that BAC prevalence was around 12.7% among women in breast cancer screening programs. Also in this investigation, age, diabetes and parity were confirmed as independent predictors of BAC International Journal of Cardiology 220 (2016) 310–311 ⁎ Corresponding author at: Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100 Rovigo, Italy. E-mail address: roncon.loris@azisanrovigo.it (L. Roncon). http://dx.doi.org/10.1016/j.ijcard.2016.06.266 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard