When you have a mammogram, it’s fair to say your focus is on whether you might have cancer. But what if the scan also revealed your risk of cardiovascular disease, a condition that kills around seven times more women in the UK than breast cancer?
Recent research suggests that, in the very near future, mammograms could be routinely used for just that.
There is no doubt we need to be spotting cardiovascular disease in women sooner – it claims over 80,000 women’s lives a year in the UK and a landmark study in The Lancet in 2021 concluded that women with it are ‘understudied, under-recognised, underdiagnosed, and undertreated’.
I see the result of this all the time in A&E. I recently treated a woman in her late-60s who was having a heart attack. She needed urgent surgery to open up a blocked artery.
In fact, as we later discovered, she’d suffered this same pain two days earlier, but because it didn’t fit neatly into the textbook picture – ‘crushing’ chest pain spreading down the left arm – it was dismissed by an A&E doctor as muscle strain from gardening.
In fact, that pain was almost certainly unstable angina, a warning that an artery supplying her heart was becoming critically narrowed. If that had been recognised, she could have been admitted, and if needed, had a stent (a mesh tube) inserted to open the artery before it was blocked.
Recent research suggests that, in the very near future, mammograms could be routinely used for revealing risks of cardiovascular disease
In other words, there was a real chance the heart attack could have been prevented – and so, too, potential long-term damage.
The truth is doctors are not as good as we should be at recognising heart disease in women, or understanding their risk.
Part of the reason is a longstanding bias in medical research and education, which is based predominantly on men.
The classic heart attack – that crushing chest pain, often spreading to the arm or jaw – is the male pattern. But a heart attack can look different in women.
Hormonal factors play a part, and women are more likely to have problems affecting the smaller blood vessels of the heart, rather than just one large artery. This may explain why women can develop broader symptoms, including breathlessness, nausea, fatigue or pain in the back, neck or jaw.
A study by the University of Leeds in 2016, which analysed more than half a million heart attack patients, found that women were around 50 per cent more likely to have been given the wrong diagnosis when they arrived in hospital. And those initially misdiagnosed had a 70 per cent higher risk of dying within 30 days than those whose heart attack was detected from the start.
There is also a bias with risk factors – we all know about smoking, high blood pressure, diabetes and high cholesterol, but there are important female-specific risks for cardiovascular disease that are given less attention than they deserve.
These include pre-eclampsia (high blood pressure in pregnancy), gestational diabetes (also during pregnancy), premature menopause and polyendocrine metabolic ovarian syndrome (previously known as polycystic ovary syndrome).
Yet these are still not routinely part of the conversation when we assess a woman’s heart risk. We need to get much better at finding cardiovascular risk in women long before they arrive in A&E.
And the answer may lie in the mammograms women are already having (every three years between the ages of 50 and 71).
When blood vessels become damaged, calcium can start to build up in their walls.
Radiologists have known for years that calcium can also sometimes build up in the breast arteries, seen on a mammogram. This is not the same as the calcium in fatty plaques inside the coronary arteries – it builds up in a different part of the artery wall – but we know that women with more breast arterial calcification are more likely to go on to have a heart attack or stroke. That’s why some radiologists flag this up to the doctor.
Compared with women with no calcification, those with mild calcification had around a 30 per cent higher risk of a major cardiovascular event such as a heart attack or stroke
Yet rather than relying on an individual radiologist, research now shows that artificial intelligence (AI) can measure the calcium automatically.
In a study, published in the European Heart Journal, researchers used AI software trained to recognise arterial calcification in mammograms taken for cancer checks from more than 123,500 women in the US. The AI classified the women as having ‘no’, ‘mild’, ‘moderate’ or ‘severe’ calcification in the breast. The researchers then compared this with the women’s medical records over seven years.
The results were striking. Compared with women with no calcification, those with mild calcification had around a 30 per cent higher risk of a major cardiovascular event such as a heart attack or stroke. Those with moderate calcification had around a 75 to 80 per cent higher risk – while women with severe calcification had roughly three times the risk.
But most importantly, even after the usual risk factors for cardiovascular disease (e.g. obesity, smoking) were taken into account, the breast arterial calcification still carried an extra risk.
In other words, the mammogram was telling doctors something extra that the normal risk factors alone miss.
And this is what makes it so exciting. The mammogram has already been done, so the calcification data could be sent to a woman’s GP with her breast-screening result. With this information, the GP could check the woman’s cardiovascular risk properly and where necessary offer treatment – for example, to lower blood pressure or cholesterol more aggressively than they otherwise might.
Until the NHS incorporates this technology routinely into breast screening, we need to look for cardiovascular risk in other ways.
And if you’re middle-aged or older, a coronary artery calcium scan can be useful. This is a quick CT scan to examine the arteries supplying the heart.
Blood tests that look for lipoprotein(a) – an inherited cholesterol-carrying particle which can increase cardiovascular risk even when ordinary cholesterol looks reassuring – can also uncover additional risk. Higher levels of apolipoprotein B, or ApoB, are another risk factor because they reflect the number of potentially artery-damaging cholesterol particles circulating in the blood.
These tests are not routinely offered on the NHS if you’re healthy, but that doesn’t mean they’re not useful – it’s about the cost. But if you can afford a detailed private cardiovascular assessment, especially if you have a family history, or have previously been diagnosed with pre-eclampsia or gestational diabetes, I think it is worth considering.
Retinal photography – used in eye screening for diabetes – can also contain information about future cardiovascular risk, because changes in the tiny blood vessels at the back of the eye reflect what is happening elsewhere. And chest CT scans may reveal calcium in the coronary arteries and identify people at risk of a heart attack.
Perhaps the future of medicine is not about doing more tests, it is about getting more information from the ones we already do.
And when you get your next mammogram back, ask if the radiologist commented on any breast calcification. If they did, it’s time to look at your risk factors such as cholesterol and blood pressure.
@drrobgalloway
Making Martha’s Rule work in A&E
Martha’s Rule is now being extended to every A&E in England, including waiting areas. I think this is a brilliant idea: It could be life-saving.
The principle is simple. A patient is getting worse, they or their family can see something is not right but feel their concerns aren’t being taken on board. Martha’s Rule gives them another route to escalate things – requesting a rapid review from a different team.
And actually we probably need this in A&E now more than ever before, with some patients spending days waiting for a hospital bed.
Monitoring these patients properly in an overcrowded A&E, particularly in a corridor, can be incredibly difficult. Families may be the first to notice that someone is deteriorating. But there is a danger, too.
Martha’s Rule must be about deterioration, not simply getting a second opinion because someone disagrees with a diagnosis, the decision to discharge or a long wait.
Otherwise there could be unintended consequences. If clinicians are repeatedly diverted to deal with disagreements rather than genuine acute deteriorations, it could actually make it harder to do the thing we should be doing in the first place: Preventing patients deteriorating in A&E.
The principle is excellent. But the rollout needs very clear rules.
