Beyond the Coronaries: Utility of Extra-Coronary Calcification for Cardiovascular Risk Assessment in Women

Globally, cardiovascular disease (CVD) is the leading cause of mortality in women. Traditional risk calculators underestimate atherosclerotic cardiovascular disease risk (ASCVD), particularly in women classified as low or intermediate risk. While coronary artery calcium scoring improves risk stratification, it remains underutilized in practice. Extra-coronary calcification (ECC), including breast arterial calcification, valvular calcification, and thoracic aortic calcification have emerged as promising adjunctive imaging biomarkers for cardiovascular risk assessment in women.

The processes of vascular and valvular calcification are influenced by inflammation, osteogenic signaling pathways, and sex hormones. Unique female factors, such as the menopausal transition, parity, and pregnancy-related complications, further influence calcification. The incidental ECC detection that is possible through screening mammography, echocardiography, and chest computed tomography offers an opportunity for cardiovascular risk identification without additional cost or radiation. Evidence has suggested ECC to be independently associated with coronary artery disease, stroke, heart failure, atrial fibrillation, and cardiovascular mortality. Further, studies have shown links between ECC with higher cardiovascular risk, particularly among women whose risk may be underestimated by traditional tools. In women, ECC may be valuable as a complementary ASCVD risk-enhancing marker, serving to augment and expedite preventive care. Heterogeneity in ECC recognition, a lack of standardized scoring, and limited prospective outcome data have prevented the integration of ECC metrics into cardiovascular guidelines to date. Future efforts should prioritize standardized reporting, artificial intelligence-assisted quantification, and well-designed prospective trials to determine whether ECC-guided prevention might improve cardiovascular outcomes in women.