When it comes to heart disease, women are often underdiagnosed. In fact, many people think breast cancer is the greater villain. Yet statistics show that although 1 in 25 women may eventually die of breast cancer, half will die of heart disease.
A new study may help link both diagnoses in a positive way, by helping to detect heart disease before heart attacks occur. It involves an expanded interpretation of a common breast cancer screening test: the mammogram. A radiologist interpreting a mammogram must distinguish between the normal calcification that can be seen in some women's breast tissue from something called breast arterial calcification. The difference is not routinely reported.
But when the actual arteries of the breast show evidence of calcification (easily detectable by digital mammography), the new trial suggests, it is an early marker of premature atherosclerotic disease - and evidence of increased risk of a future heart attack.
This fascinating trial looked back at 292 asymptomatic women who had both a digital mammogram and a CAT scan of the chest, both for reasons unrelated to the study. Some of the CAT scans showed calcium in the coronary arteries.
A similar but more specific test, called a calcium scoring CAT scan, has been used by cardiologists for years. It can identify people at risk of developing coronary artery disease who have a strong family history, determine the need for statin therapy for borderline elevations of cholesterol, and identify the need for preventive measures. The new study, published in the Journal of the American College of Cardiology: Cardiovascular Imaging, found a strong correlation between the presence of breast arterial calcification seen on mammograms, and coronary artery calcification found incidentally on CAT scans.
Just think of the potential implications. Women whose mammograms show breast arterial calcification could be singled out as higher risk before they actually develop a problem. As Mary Walsh, vice president of the American College of Cardiology, put it, this could be a "two-fer" for women, offering information about the risk of heart disease and breast cancer.
This is just one retrospective study. It is uncommon for doctors to change medical practice based on information not yet backed up by multiple randomized trials, and there are no such trials showing that either calcium scoring tests or breast arterial calcification testing improves cardiac outcomes. It is possible that acting now on positive results from mammograms could lead to unnecessary further diagnostic studies rather than being used as a marker of increased risk. And that, in turn, could lead to undue anxiety - rather than constructive lifestyle changes - in the women with high calcium scores.
But let's look at a few facts. Women have a worse prognosis and die more often than men after they have a heart attack or undergo bypass surgery. Nearly two-thirds of sudden deaths due to heart disease involve women with no previous symptoms, compared with about half of such deaths in men. The best answer for women is to detect risk and prevent problems.
The key to prevention is to modify the risk factors that lead to heart disease. These include cigarette smoking, obesity, high blood pressure, high cholesterol, diabetes, being sedentary, stress, and eating poorly.
Still, wouldn't it be something if we had a test exclusively for women, able to predict a higher risk for heart disease, so they might begin to take the steps to avoid a problem in the future?
Here are some thoughts about what the new study findings should lead to:
Immediate documentation of breast arterial calcification on all mammography reports.
Efforts to further the cooperation among the radiologists who interpret these studies, the primary care doctors who receive the reports, and cardiologists who can implement appropriate preventive strategies. Results from a redesigned mammography report would be a powerful incentive to induce lifestyle change, and identify and treat such risk factors as high blood pressure, diabetes, and high cholesterol.
Advocacy by women's groups to push for rapid adoption of a new standard. In the U.S., about 37 million mammograms are performed every year. If 10 percent show evidence of newly detected subclinical coronary artery disease, almost four million women a year may be affected.
Patients should ask their doctors whether their mammography reports included a breast arterial calcification comment. If it didn't, they should request it.
As a physician, I usually hope to see multiple trials showing that an intervention is helpful before it is adopted. In this case, although more studies need to be conducted, there is no time to waste. These changes should be implemented now, as sticking with the status quo will only continue the disparity between the sexes in matters of the heart.
Dr. David Becker is a board certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown, Pa. and has been in practice for 25 years. In 1993, after extensive research, Dr. Becker launched Healthy Change of Heart™, an innovative 10-week program designed to reverse heart disease and improve quality of life through diet, exercise, and stress management. Since then, thousands of patients have participated in the program, achieving significant results in improving cardiac wellness.
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