Atherosclerotic cardiovascular disease (ASCVD)

Atherosclerotic cardiovascular disease (ASCVD) is one of the most serious health challenges of our time, accounting for the leading cause of death worldwide¹. Understanding ASCVD is especially important for those living with diabetes, as the two conditions are closely linked and can amplify each other’s risks.

Atherosclerotic cardiovascular disease (ASCVD) occurs when fatty deposits, or plaques, build up inside the arteries^1,2.

ASCVD can be detected by coronary artery calcium (CAC) scans (a marker of plaque), blood tests, electrocardiogram (ECG), MRI, and other imaging tests³. Other ASCVD risks, including heart attack, can be determined using an ASCVD risk estimator in accordance with clinical practice guidelines³.

Without treatment, ASCVD can lead to serious complications such as myocardial infarction, heart failure, or stroke². This emphasises the importance of cardiovascular risk assessment, and potential risk lowering interventions such as medication and positive lifestyle changes^2,3.

ASCVD is an umbrella term that includes several major conditions caused by atherosclerosis, especially in adults. These are:

• Coronary artery disease (CAD): A condition where the arteries supplying your heart muscle with blood, oxygen, and nutrients become narrowed or blocked by a buildup of fatty plaque (atherosclerosis).
• Peripheral artery disease (PAD): A circulatory condition that causes narrowed arteries, reducing blood flow to the arms and most commonly to the legs.
• Renal artery stenosis: Occurs when fatty plaque accumulates in the arteries that carry blood to the kidneys, restricting blood flow which can lead to high blood pressure and kidney damage.
• Vertebral artery disease: Atherosclerosis in the arteries that deliver blood to the back part of the brain that is responsible for vital functions that sustain life.
•  Mesenteric artery ischaemia: Develops when plaque builds up in the arteries supplying blood to the intestines, blood flow and causing damage to the intestinal tissue¹.

ASCVD is a progressive condition that develops slowly over many years¹. Early stages are often silent, with subclinical atherosclerosis detectable before symptoms arise^1,2. Lifestyle management at this stage can help reduce risk^1,2. As the disease progresses, common symptoms may include:

●       Chest pain or angina^1,2

●       Shortness of breath²

●       Arm or leg pain, especially when exercising²

●       Ongoing fatigue²

●       Feeling confused²

There are a number of ASCVD risk factors that may contribute to its progress, especially those categorised as intermediate risk that can quickly lead to increased risk if not managed properly^1,2. These include:

●       High cholesterol (especially raised LDL cholesterol)^1,2

●       High blood pressure²

●       Smoking and tobacco use^1,2

●       Unhealthy lifestyle¹

●       Diabetes mellitus²

●       Genetic predisposition and family history^1,2

People with diabetes, especially those with type 2 but including those with type 1 diabetes, are two to four times more likely to develop cardiovascular disease than those without diabetes⁴. The relationship is so strong that cardiovascular complications, including nonfatal myocardial infarction and nonfatal stroke, along with other factors such as being a current smoker, are often described as the primary cause of death in people with diabetes⁴.

Chronically elevated blood sugar (hyperglycaemia) damages the delicate lining of blood vessels (endothelium), particularly when fasting glucose is ≥126 mg/dL, the threshold for diagnosing diabetes^4,5. Over time, this causes microscopic injuries that allow cholesterol and fatty deposits to attach to artery walls, accelerating plaque formation and driving the development of ASCVD¹.

Type 2 diabetes is marked by insulin resistance, where the body does not respond effectively to insulin. This raises blood sugar and triggers low-grade, long-term inflammation. While lifestyle changes can help reduce this risk, chronic inflammation destabilises plaques, making them more likely to rupture and cause heart attacks or strokes⁶.

Statin therapy can be used to help manage this risk by reducing cholesterol production in the liver, lowering blood cholesterol levels, and slowing plaque buildup that can lead to heart attack or stroke⁷.

Diabetes often disrupts lipid metabolism, causing diabetic dyslipidaemia, which is marked by:

• Higher LDL cholesterol ("bad cholesterol")
• Lower HDL cholesterol ("good cholesterol")
• Elevated triglycerides

Together, these changes greatly increase the risk of atherosclerosis and ASCVD events such as heart attacks and strokes⁸.

High blood pressure is common in people with diabetes, and together they greatly magnify ASCVD risk. Hypertension strains vessels already damaged by glucose and lipid abnormalities, including high total cholesterol, and contribute to endothelial dysfunction, increasing the risk of heart disease⁹. Smoking cessation is therefore vital, and risk estimates should also account for conditions such as chronic kidney disease^9,10.

This multifactorial relationship means diabetes acts as both a direct and indirect driver of ASCVD, underscoring the need for regular ASCVD risk assessment. Current clinical guidelines recommend assessing 10-year ASCVD risk and making primary prevention of cardiovascular disease a core part of diabetes care¹⁰.

Preventing ASCVD in people with diabetes requires a holistic approach combining lifestyle changes, medical therapy, diabetes treatment and long-term monitoring. Tools like the ASCVD risk calculator can also help with risk management¹⁰.

• Heart-healthy diet: Reduce saturated fats, refined sugars, and processed foods; increase fibre, fruits, vegetables, and whole grains to support blood sugar and cholesterol control⁷.
• Regular physical activity: At least 150 minutes of moderate exercise (e.g., walking, cycling, swimming) improves insulin sensitivity, lowers blood pressure, and strengthens the heart⁷.
• Weight management: Losing just 3-5% of body weight can improve glucose control and reduce cardiovascular strain⁷.
• Quit smoking: Smoking accelerates arterial damage and doubles cardiovascular risk⁷.
• Limit alcohol: Excess intake raises blood pressure and disrupts glucose control⁷.

• Statins: Lower LDL cholesterol and stabilise plaque buildup⁷.
• ACE inhibitors or ARBs: Control blood pressure and protect kidney function in diabetes⁷.
• Glucose-lowering therapies with cardiovascular benefits: SGLT2 inhibitors and GLP-1 receptor agonists both reduce blood sugar and ASCVD risk⁷.
• Antiplatelet therapy: Low-dose aspirin may be considered in high-risk patients to lower clotting risk⁷.

ASCVD prevention is not a one-time effort. People with diabetes should have regular check-ups scheduled, including:

• Blood pressure checks¹¹
• Cholesterol and lipid panels¹¹
• HbA_1c tests (to track long-term glucose control)¹¹
• Foot and kidney health assessments¹⁰

This comprehensive monitoring supports early intervention if risks increase.

Nutrition is one of the most powerful tools for managing diabetes and lowering ASCVD risk, alongside appropriate statin dosing. A heart-healthy diet supports stable blood glucose, healthy cholesterol levels, including LDL-C and long-term cardiovascular wellbeing, and helps individuals lose weight⁷.

• Choose fibre-rich foods: Wholegrains, beans, vegetables, and fruits help control both cholesterol and post-meal blood sugar spikes¹⁰.
• Pick healthy fats: Replace butter and processed oils with olive oil, avocado, nuts, and seeds¹⁰.
• Opt for lean protein: Poultry, fish, tofu, and legumes provide protein without excess saturated fat¹⁰.
• Include omega-3 fatty acids: Fatty fish like salmon, mackerel, and sardines reduce inflammation and support heart health¹⁰.
• Limit sodium intake: High salt levels increase blood pressure, a major risk factor for ASCVD¹⁰.
• Stay hydrated and watch portion sizes: Balanced eating patterns prevent weight gain and stabilise energy levels¹⁰.

• Cook at home to control ingredients.
• Use wholegrain foods as much as possible.
• Pair carbohydrates with protein or healthy fats to slow glucose absorption.
• Be mindful of portion sizes¹²

When combined with glucose monitoring and prescribed therapies, these dietary measures form a cornerstone of ASCVD prevention in people with diabetes⁶.

The link between diabetes and ASCVD is undeniable, but the outlook is not bleak. With effective preventive strategies, individuals can lower their lifetime risk despite the higher prevalence of ASCVD in people with diabetes. For healthcare providers, this means making cardiovascular risk reduction a primary focus and widely accepted routine part of diabetes management. For patients, it means consistent lifestyle changes and close collaboration with their care team.

With early intervention, lifestyle modification, and modern therapies, including considerations for therapy impact, the priority should be primary prevention that protects cardiovascular health and supports longer, healthier lives.

Diabetes raises heart disease risk by driving high blood sugar, high blood pressure, insulin resistance, and unhealthy cholesterol levels. Over time, hyperglycaemia, particularly when levels reach high milligrams per deciliter (mg/dL), damages blood vessels and nerves, leading to atherosclerosis (plaque buildup). Insulin resistance raises LDL (“bad” cholesterol) and lowers HDL (“good” cholesterol), while hypertension strains the heart and arteries - all of which increase cardiovascular risk.

Yes. Statins lower LDL cholesterol, ACE inhibitors and other blood pressure drugs control hypertension, and aspirin may reduce clotting risk in select patients. Newer agents such as GLP-1 receptor agonists and SGLT2 inhibitors can lower blood sugar and reduce cardiovascular risk. The right treatment plan should be tailored with a healthcare provider.

Signs can vary, but common ASCVD symptoms include:

• Chest pain or discomfort (especially during activity or stress), often worsened by high blood cholesterol
• Shortness of breath or fatigue
• Dizziness or lightheadedness
• Swelling in the legs, ankles, or feet
• Irregular heartbeats or palpitations

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