When you have a mammogram, it’s fair to say your focus is on whether you might have cancer.
uncertain
you → 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
asserted
that → reveal → cancer
Recent research suggests that, in the very near future, mammograms could be routinely used for just that.
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mammograms → suggest → 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’.
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women → be → it
I see the result of this all the time in A&E.
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I → see → A&E.
I recently treated a woman in her late-60s who was having a heart attack.
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who → treat → attack
She needed urgent surgery to open up a blocked artery.
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She → need → 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.
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it → discover → gardening
In fact, that pain was almost certainly unstable angina, a warning that an artery supplying her heart was becoming critically narrowed.
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artery → supply → heart
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.
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it → recognise → artery
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.
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attack → suggest → words
The truth is doctors are not as good as we should be at recognising heart disease in women, or understanding their risk.
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we → recognise → risk
Part of the reason is a longstanding bias in medical research and education, which is based predominantly on men.
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which → base → men
The classic heart attack – that crushing chest pain, often spreading to the arm or jaw – is the male pattern.
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attack → crush → arm
But a heart attack can look different in women.
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attack → look → 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.
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women → play → artery
This may explain why women can develop broader symptoms, including breathlessness, nausea, fatigue or pain in the back, neck or jaw.
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women → explain → back
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.
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they → analyse → 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.
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attack → misdiagnose → 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.
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they → be → attention
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).
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These → include → syndrome
Yet these are still not routinely part of the conversation when we assess a woman’s heart risk.
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we → assess → 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).
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women → need → 50
When blood vessels become damaged, calcium can start to build up in their walls.
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calcium → become → walls
Radiologists have known for years that calcium can also sometimes build up in the breast arteries, seen on a mammogram.
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calcium → know → 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.
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women → build → attack
That’s why some radiologists flag this up to the doctor.
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radiologists → ’ → 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.
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intelligence → compare → calcium
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.
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researchers → publish → US
The AI classified the women as having ‘no’, ‘mild’, ‘moderate’ or ‘severe’ calcification in the breast.
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AI → classify → breast
The researchers then compared this with the women’s medical records over seven years.
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researchers → compare → years
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.
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those → compare → attack
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.
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women → have → 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.
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calcification → take → risk
In other words, the mammogram was telling doctors something extra that the normal risk factors alone miss.
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factors → tell → that
And this is what makes it so exciting.
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it → make → ?
The mammogram has already been done, so the calcification data could be sent to a woman’s GP with her breast-screening result.
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data → do → 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.
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they → check → pressure
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.
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scan → incorporate → ways
This is a quick CT scan to examine the arteries supplying the heart.
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This → examine → heart
…and 19 more, not listed.
The Aporia
