What Are We Waiting for? Khurram Nasir, MD on Using Mammograms to Find Heart Risk

Editor's Note: In research due to be presented next week at the American College of Cardiology’s 65th Annual Scientific Session and Expo, a Mount Sinai Hospsital, NY team found that microcalcifications in mammograms could predict heart disease. Khurram Nasir, MD (photo) is co-author of a JACC editorial responding to the findings.

Q & A with Khurram Nasir, MD, Research Director, Center for Prevention and Wellness, Director, High-rRsk Cardiovascular Disease Clinic

Baptist Health South Florida, Miami, Florida;Assistant Professor, Johns Hopkins Ciccarone Center for Preventive Cardiology

Baltimore, Maryland

Q:What aspect of this study most clearly sets it apart from previous breast artery calcification (BAC)/cardiac artery calcification research?

Although a few prior studies have shown an association of the presence of BAC and presence of CAC, this earlier work provided little guidance on the practical value of the findings in clinical practice. The Mount Sinai study is clearly set apart from prior studies by robustly studying the interplay of risk factors for cardiovascular disease (CVD) used in current guidelines and the detection of BAC and CAC as a marker of atherosclerotic disease.

Q: What are some of the highlights of the study for you?

There were three key points. The study clearly showed that those with higher CVD risk burden had a higher likelihood of BAC.

Second, as compared to traditional algorithms for assessing risk and subsequent CVD preventive management, the study found that the presence of BAC alone was predictive of CAC, more so even than age or presence of hypertension.

In my opinion the most important finding of the study was the robust positive predictive value of nearly 70% for identifying women with presence of CAC. Even among younger women, 50% with BAC had demonstrable CAC. As such, even by a conservative estimate that 10% that means that approximately 4 million women nationwide undergoing screening mammography will exhibit BAC; with 2-3 million of them likely have signs of premature coronary atherosclerotic disease. They can then be referred for care.

Q: Why have health care providers been slow to adapt such a strategy despite the potential cost savings and health benefits?

This is a key question and I have spent a lot of time contemplating on this issue in my editorial. In spite of significant evidence in the past listing presence of BAC as a possible risk factor for atherosclerotic disease and hard CVD outcomes such as heart attacks, strokes, heart failure, there has been a lack of sustainable and standardization action.

Guidelines have not been updated. Specialty societies have failed to recognize its value and have not incorporated it into healthcare delivery protocols. The lack of action by our medical community is disconcerting.

Q: What is the consequence of this inaction?

Nearly 37 million to 40 million women each year undergo mammogram studies. Even with a conservative estimate that 10% will have BAC nearly 2 million to 3 million will have CAC and at higher risk for future CVD risk.

We could identify these patients easily because the information is available without any additional cost/radiation or testing to optimally manage these vulnerable individuals.

Actually the risk of the presence of CAC--the strongest marker for risk of a future CVD event-- with BAC may be a risk factor that is even higher than diabetes.

Q: But again, why has this happened, why such a delay on the uptake?

I think the medical community’s slow adoption can be attributed to the cliched response of ‘lack of clinical trial.’ The community is ignoring significant real-world data instead of incorporating major changes in practice.

Q: What about more trials?

Do we need clinical trials? Yes --but the lack of them in this case should not be allowed to justify the current state of inertia.

Our stakeholders are well within their rights to ask, what threshold of critical information will inspire pragmatic changes in how we practice medicine? I think it’s time we act on the information; remaining a silent bystander waiting for another study and preserving status quo should not be an option.

Q: What needs to happen now?

The next steps are very clear.

We need to pause and garner consensus on constructing best practices on what we already know.

There is little doubt, based on the principles of clinical equipoise, that BAC is strongly associated with early atherosclerotic disease and its detection should be actively pursued in all mammograms performed

Reporting BAC and subsequent management of these patients should be tracked as part of the core quality-performance measures.

A concerted effort is needed among medical stakeholders (radiologists, primary care and cardiologists) and their respective societies for the following,

a) supporting the widespread documentation of BAC in mammography reports

b) improving the education of primary care and radiology providers regarding the link between BAC and atherosclerotic CVD,

c) mandatory reporting of BAC in mammogram studies

d) establishing detection of BAC and downstream action as standard of care and performance measures

We need to develop a consensus on further research for establishing best practices that can facilitate successful translation of this widely available, but often widely ignored, science.