Extracardiac imaging biomarkers of cardiovascular health: a comprehensive review

Cardiovascular disease (CVD) is the leading global cause of morbidity and mortality. Beyond clinical risk factors and cardiac imaging, extracardiac imaging biomarkers provide complementary insight into cardiometabolic health. Routine noncardiac imaging often depicts the liver, kidneys, pancreas, lung, brain, adipose tissue, muscle, vasculature, breast, and bone, enabling opportunistic risk assessment. Nonalcoholic fatty liver disease (NAFLD), detectable on MRI, CT, and ultrasound, independently predicts major adverse cardiovascular events (MACE). Chronic kidney disease-related markers including kidney size, vascular calcification, and renal resistive index also correlate with adverse outcomes. Reduced pancreas volume is similarly associated with cardiovascular disease. CT-quantified emphysema and lung hyperinflation are associated with coronary artery disease and cardiovascular mortality. Cerebral small vessel disease markers, such as white matter hyperintensities and silent brain infarcts, demonstrate associations with cardiovascular events. Ectopic adiposity and sarcopenia quantified by CT, MRI, and ultrasound add prognostic value beyond body mass index. Extracardiac vascular and skeletal biomarkers, such as breast arterial calcification and low bone mineral density, further associate with cardiovascular morbidity and mortality. Collectively, these markers improve risk stratification and enable screening without added cost or radiation. Future priorities include standardization, external validation, and integration into risk prediction models to advance precision cardiovascular medicine.