What Happened When a Doctor Asked a Mammogram About Her Heart

This article is reposted from Still Becoming, a Substack authored by Selfority founder and CEO, Dr. Sarah Berg.

On October 9, the Selfority team spent the day at the Yale Club in New York for the first convening of InAWH, the Institute Advancing Women’s Health. The following week, Dr. Berg stood in a mammography suite with her left breast flattened between two plates of plastic, trying to make small talk with the technologist about cardiology.

Here's what happened when Dr. Sarah Berg asked to be screened for BAC during her regular mammogram

Most women get through their annual screening by holding their breath and planning lunch, which is a perfectly respectable coping strategy and one I have relied on for years. This time I was focused on what else was on the film.

What else was on the film, you may ask, is breast arterial calcification, or BAC: thin white tracks of calcium lining the walls of the small arteries in the breast. They have shown up on mammograms for as long as there have been mammograms, and radiologists see them all the time. Because BAC has nothing to do with breast cancer, and breast cancer is what a mammogram is built to find, it has mostly lived in the incidental-finding drawer. Over the last decade, research has been piling up around the idea that those little white lines might have something to tell us about the heart, too.

That idea was a big reason why InAWH brought us together. Over a day of conversations, we heard from a cardiologist, a gynecologist, and a lineup of other physicians, some talking about BAC, some about how little most of us were ever taught about midlife, and all of them circling back to how we take care of women. But BAC was the initiative at the center of the room. By the time I got home, I had already decided I was going to ask about my own films.

So I asked. At the front desk, before I went back to my ‘dressing room’ to put on my beautiful white robe, I asked the women checking me in if this was something the radiologist could read and put in my report. This request made it first to the mammogram tech, then to the radiologist herself. After my scan, the radiologist was generous and refreshingly honest with me. Her center doesn’t have a grading system for BAC yet, and she told me straight out that reading and reporting it is still controversial in her field.

Why is screening for BAC important?

I’ll admit my reason for pushing for the BAC was more personal than professional. Both of my grandfathers had multiple heart attacks. My father, an interventional cardiologist who has spent his career opening other people’s arteries, had a TIA in his fifties and a heart attack this past year. Nearly everyone in my family takes something for cholesterol or blood pressure (holidays at our house come with a pill organizer at every place setting), and my own history piles on: a stillbirth, preeclampsia, gestational hypertension, a preterm delivery, and postpartum depression.

The 2019 ACC/AHA prevention guideline counts preeclampsia as a risk enhancer for later heart disease, so my obstetric chart already reads like a cardiology referral nobody ever sent. Heart disease is the leading cause of death for women in this country. I want every honest look at my arteries medicine is willing to give me, and this one was already sitting on a film I was going to get anyway.

Is BAC screening included in regular mammography testing?

Maryland is the first state to step into the screening issue. On October 1, House Bill 1364 took effect, and mammography centers there now have to include a paragraph about BAC in the results letter federal law already requires them to send. The required notice tells women that BAC is common, that it may point to a higher risk of cardiovascular disease, and that they should talk with their physician about whether more testing makes sense. Anyone who has read her own mammogram letter will recognize the format, since it borrows almost word for word from the breast density notice sitting right above it.

What the bill doesn’t do is tell anyone how to find, measure, or grade BAC. A clause makes clear the notice creates no standard of care and no grounds for a lawsuit, no funding comes with it, and follow-up gets exactly one line letting the patient know a report went to her physician. (Somewhere a primary care doctor just felt a chill.) The state health department can change the wording by regulation as the evidence evolves, which reads to me like an admission that the evidence is still evolving. Breast radiologists at Johns Hopkins wrote to lawmakers opposing the bill, calling it premature and worrying it could pull mammography away from its main job of finding cancer.

What are the links between BAC and heart disease in women?

The link between BAC and heart disease shows up again and again in the research. In one of the most careful studies, Kaiser Permanente Northern California followed 5,059 women aged 60 to 79 for about six and a half years after a screening mammogram. About a quarter of them had BAC, and after accounting for the usual risk factors, those women had a 51 percent higher hazard of heart attack or stroke. Adding BAC to the standard risk calculator moved a modest number of women into more accurate risk categories.

The authors made the case that BAC should count as a risk-enhancing factor for postmenopausal women, which is a gentle way of pointing out that our guidelines don’t count it yet. (The 2019 ACC/AHA guideline does count premature menopause and preeclampsia. BAC didn’t make the list.)

This year the studies got big. Researchers writing in the European Heart Journal used AI to measure BAC on mammograms from 123,762 women across two health systems, and the more calcium they found, the higher the risk climbed: about 30 percent higher risk of a major cardiovascular event with mild BAC and close to triple with severe BAC, even after factoring in the American Heart Association’s PREVENT score. A multicenter study in JACC: Cardiovascular Imaging followed 21,514 women in the US and Australia and ranked each woman’s BAC against other women her age. Among the women the standard calculator considered low risk, who made up 80 percent of the group, the ones with BAC still had significantly more events. A 2026 meta-analysis pooling 24 studies and more than 236,000 women linked BAC to higher rates of death, heart failure, stroke, and heart attack.

All of those numbers are about prediction. Nobody has shown yet that telling a woman about her BAC, and then doing something about it, prevents a heart attack or buys her more years. Medicine has a long and slightly embarrassing history of falling hard for markers that predicted beautifully and then changed nothing once we started treating them, and I would love for BAC to stay out of that club.

The bump in prediction is also smaller than the headlines make it sound. In the US and Australian study, adding BAC nudged the model’s accuracy from 0.67 to 0.71, which is real and also modest. Several of that paper’s authors list affiliations with CureMetrix, the company whose software did the measuring and which holds FDA clearance for its detection tool, and I always want to know who built the ruler before I trust the measurement.

The meta-analysis had its own catch: the link to future heart events held up only in studies that measured how much BAC was there, while Maryland’s law doesn’t standardize how a radiologist says whether it’s there at all.

What is BAC?

It helps to know what BAC is, biologically. Most of it sits in the muscular middle layer of the artery wall, called medial calcification, and is a different process from the cholesterol plaque in the inner lining that a coronary calcium scan picks up. Medial calcification travels with aging, kidney disease, and diabetes, and warfarin speeds it up almost fourfold in women with normal kidney function. A calcified breast artery may say as much about how our arteries are aging, and how our kidneys are doing, as about what’s going on in the coronaries. In one Brazilian study of postmenopausal women who already had coronary disease, BAC didn’t predict how many vessels were blocked.

Then there’s the woman whose letter comes back with nothing flagged.

In the Canadian BEACON study, 286 women with no known heart disease had both a mammogram and a research cardiac CT. When BAC showed up, it almost always meant calcium in the coronaries too (92 percent specificity, for my fellow nerds), but it missed most of the women who had coronary calcium (23 percent sensitivity). A third of the women with clean breast arteries still had calcium in their hearts. I keep picturing one of them opening her Maryland letter, seeing nothing, and exhaling, and I’m not sure any of us knows yet what we’re supposed to tell her.

BEACON had good news in it, too. Among the women with both BAC and coronary calcium, 71 percent weren’t on a cholesterol medication, and 63 percent didn’t think their heart risk was elevated. After they found out, 92 percent made an appointment with their primary care doctor, and nearly half changed something about how they lived.

A notification study from Northwell found that 57 percent of women told about their BAC went on to talk about it with a primary care doctor or cardiologist, and three out of four said every woman should be told. Women have been asking for this for a while. In a 2018 Mount Sinai survey, 96 percent of mammography patients wanted BAC in their report.

Is BAC screening more about prevention or is it a scare tactic?

Where I land is that it depends on what’s waiting on the other side of the letter. In that Mount Sinai survey, most women said they’d want a coronary CT before deciding anything, and right now whether a woman gets one depends on which doctor opens the report, what that doctor knows about BAC, and what her insurance feels like covering that day.

Who has BAC changes the planning, too. A 2026 study of more than 4,300 screening patients without known heart disease found BAC in about 8 percent, more often in Black and Hispanic women after adjusting for age and less often in women currently using hormone therapy. The menopause doctor in me perked right up at that last one, and I also know a single snapshot like this can’t tell us hormone therapy prevents anything.

And somebody has to do the reading.

When the American College of Radiology surveyed its members, 87 percent said they mention BAC at least some of the time, but only 41 percent did it always or most of the time. Most simply noted it was there, about 1 percent gave it any kind of score, 58 percent made no follow-up recommendation, and the field had no consensus on whether patients should be told at all. Maryland’s law adds a paragraph to a letter without adding a dollar to anyone’s reimbursement. Measuring BAC well seems to take software, software costs money, and the company behind one of the FDA-cleared tools has said there’s no CPT code for mammography AI. We’re asking breast radiologists, who are already stretched thin, to add a cardiac read for free.

Then the letter lands on the desk of whoever ordered the mammogram, which is very often a gynecologist. People like me. I’d love to tell you every one of us is fluent in PREVENT scores, statin conversations, and when to send someone for a calcium scan, and I’d also love to tell you I enjoy mammograms. A good follow-up visit for BAC looks a lot like the visit midlife women should already be getting: blood pressure, cholesterol, blood sugar, kidney function, pregnancy history, when menopause arrived, family history, a real risk estimate, and for some women a calcium scan to see what the coronaries are up to. BAC could be the thing that finally gets that visit on the calendar, as long as someone on the other end knows how to run it.

Back to the screening room.

Here, I want to revisit that moment with the radiologist. The moment I started this essay around. After my images were read, the radiologist came to the dressing room while I was still in the robe, the one that never quite closes no matter how creatively you tie it. She wanted me to know she had looked. That she didn’t see anything worth reporting. She also wanted me to know that her software doesn’t have a scoring system for BAC yet, so looking and writing down what she saw was as far as she could go.

She did everything the current system allows and then walked down a hallway to tell a half-dressed patient exactly where the system ends. That is truly a kindness.

I got dressed and drove home with more questions than I came with. I still don’t know whether a line on my mammogram should change anything about how my heart is cared for, and right now, neither does anyone else.

We don’t know if telling women improves their outcomes. There’s no agreed way for radiologists to grade what they see, no clear person to pick up the phone when one of those Maryland letters arrives, and no way for a radiology practice to get paid for adding a cardiac read to a breast exam. People are working on every piece of this, and Maryland decided to start telling women what’s on their films before the answers were all in.

Given my family, I would rather know, and I suspect most women would too. What we owe them next is more than a paragraph in a letter, and none of us, radiologists or gynecologists or cardiologists, has quite figured out what that looks like yet.

Click here for more information about InAWH. Learn more about how menopause impacts your heart health with Menopause, Explained.