Atherosclerotic Cardiovascular Disease (ASCVD): Causes, Diagnosis, and Treatments

There are a lot of terms out there that refer to disease of the heart and blood vessels. You might be familiar with heart disease, hardening of the arteries, heart attack, and stroke. But what about the terms atherosclerosis, cardiovascular disease, or atherosclerotic cardiovascular disease (ASCVD)? It can be confusing to figure out what these terms mean. And more importantly, what they have to do with you and your health.

Read on to learn more about ASCVD, its causes, and the effects it has on the body.

What is ASCVD (atherosclerotic cardiovascular disease)?

ASCVD is the medical abbreviation for atherosclerotic cardiovascular disease. This condition is also commonly called atherosclerosis. It occurs when fatty deposits (also called plaque) build up in the arteries. The word atherosclerosis literally means narrowing (sclerosis) caused by fatty deposits (atheroma).

Atherosclerosis matters because it narrows and stiffens arteries. Arteries are blood vessels that carry blood and oxygen from the heart to the rest of the body. All organs need this flow of oxygenated blood in order to work.

But when an artery becomes atherosclerotic, or narrowed with plaque, it's difficult for blood to get through. Plaques can occur in any artery. But they're most dangerous when they affect vessels that supply blood to certain organs like the heart, brain, and kidneys.

What causes atherosclerotic cardiovascular disease?

ASCVD develops slowly over time. Experts believe it begins with injury to the inner lining of an artery. Commonly, this is caused by high blood pressure (hypertensive atherosclerosis). But there are many other causes that contribute (see below).

This blood vessel damage attracts cells and other materials to the vessel wall, where they clump together to form plaque. The plaque can gradually get bigger, blocking the artery, or it can break off and travel in the bloodstream.

How atherosclerosis contributes to heart disease

The heart is a muscle that requires its own oxygenated blood flow to function. Arteries that bring blood to the heart walls are called "coronary arteries." If one of the coronary arteries is narrowed by plaque, the heart doesn't get enough oxygen. Some people don't have symptoms at all, but others can have symptoms like chest pain (angina), shortness of breath, dizziness, or nausea. A heart attack occurs when the lack of oxygen is severe enough to damage heart muscle.

What's the difference between ASCVD and heart disease?

ASCVD is sometimes referred to as "heart disease." But this isn't entirely accurate.

ASCVD can affect any artery in the body. When it affects the arteries that supply blood to the heart, it's called coronary artery disease (CAD). So CAD is a type of ASCVD. It's also just one of many conditions that can affect the heart.

"Heart disease" is a catch-all term that can refer to several conditions that affect the heart. It can include CAD. Other types of heart disease include valve disease, arrhythmia (problems with the electrical system), and heart failure.

How atherosclerosis contributes to stroke

Just like the heart, the brain also depends on its own supply of oxygenated blood. And, just as plaques can form in the arteries that supply the heart, plaque can also form in the arteries that supply the brain.

When a part of the brain isn't getting enough oxygen, this is a stroke. A lack of oxygenated blood to the brain can lead to symptoms, such as:

• Trouble speaking

• Sudden confusion

• Problems with vision or balance

• Weakness in a part of the body

When these symptoms are temporary, it's called a transient ischemic attack (TIA, or ministroke). But it's called a stroke when the lack of oxygen to the brain results in permanent damage.

Other types of ASCVD

Just like CAD is one type of ASCVD, there are other types of ASCVD that affect different arteries in the body:

• Peripheral artery disease (PAD) is when plaques form in the arteries that carry blood to the legs and feet. It causes leg cramps while walking, pain, and coolness to touch.

• An aneurysm is a bulge in the wall of the artery. An aortic aneurysm, which affects the large artery that supplies your chest and abdomen, is particularly dangerous.

• Atherosclerotic kidney disease occurs when atherosclerosis affects the artery or arteries that supply blood to the kidneys. This can affect the kidneys' function over time.

Who's most at risk of ASCVD?

Some ASCVD risk factors can cause damage to the artery walls. This starts or accelerates the development of ASCVD. These include:

• Smoking

• High blood pressure (hypertension)

• High LDL, or "bad," cholesterol (hypercholesterolemia)

• Diabetes

• Metabolic syndrome

• Chronic kidney disease

• Diet high in saturated fat

• Not enough exercise

• Excess body weight

• High levels of stress

You can't control other risk factors. But it's important to know about them so you can have an informed discussion about your individual risk with your healthcare team. They include:

• Increasing age (over 45 years for men and over 55 years for women)

• A family history of heart disease or familial hypercholesterolemia

• Inflammatory conditions like rheumatoid arthritis

• History of preeclampsia in pregnancy

What is an ASCVD risk score?

An ASCVD risk score is a score that takes into account your risk factors, including your medical conditions, age, sex, and health habits. It estimates your risk of having ASCVD in the next 10 years.

Here's a general breakdown of what your ASCVD risk score means:

• Low risk: less than 5% risk of developing ASCVD in the next 10 years

• Borderline risk: 5% to 7.4% risk of developing ASCVD in the next 10 years

• Intermediate risk: 7.5% to 19.9% risk of developing ASCVD in the next 10 years

• High risk: 20% or more risk of developing ASCVD in the next 10 years

It's important to interpret your results with your primary care provider. They may use additional information about your health to talk with you about your risk. This information can help decide whether any medication or other preventive measures are appropriate.

How do you diagnose atherosclerosis?

There are several clues that may hint at a diagnosis of ASCVD. If you have a primary care physician, they'd have been watching for many of them in regular visits and bloodwork:

• Symptoms like chest pain and shortness of breath

• Signs on a physical exam

• Medical conditions like high blood pressure

• The medical history of your family

• Lifestyle habits, especially diet, exercise, and smoking

• Blood tests, like lipid tests (cholesterol), blood sugar, and kidney function

If you have symptoms of ASCVD, or you are at high risk for it, your primary care provider may recommend more tests. Some of the tests they use to diagnose ASCVD include the following:

• Electrocardiogram (ECG or EKG): This looks at the electrical activity of your heart. An EKG can give clues about the heart's current function and if there has been damage in the past.

• Stress test: This testing uses an EKG, echocardiogram, or other imaging study to see how well the heart works under stress. The "stress" from stress test comes from exercise on a treadmill or from a medication that makes your heart work a little harder.

• Ankle-brachial index: The ankle-brachial index (ABI) test compares the blood pressure in your arm and leg to determine if you have peripheral artery disease.

• Imaging tests: Special tests can help healthcare professionals visualize the inside of arteries. This can include angiogram, ultrasound, or cardiac CT scans and MRIs.

How do you treat atherosclerosis?

Prevention and treatment of atherosclerosis both start with a lifestyle that promotes overall health. This means:

• Eating a balanced diet: It can help to start with small changes and experiment with different foods to build a nutritious and balanced diet.

• Regular movement and exercise: The American Heart Association (AHA) recommends 150 minutes of exercise each week.

• Quitting smoking, if you smoke: It can be incredibly hard but worth it in the end.

• Find ways to manage stress: You may not be able to change circumstances causing stress, but simple steps can help you deal with it better.

In addition to the heart-healthy steps above, most people who have ASCVD will also take medications to slow down damage to the arteries. The specific medications you take depend on your specific medical condition(s).

• Blood pressure management is important to limit stress on the heart and blood vessels.

• Statin medications for cholesterol can slow down plaque formation and stabilize ones that already exist.

• Treating diabetes helps to prevent more damage to blood vessels.

• Some people at high risk of ASCVD take antiplatelet medication, like an aspirin every day. But other people are at higher risk for bleeding, so it's not appropriate for them. Your primary care physician or cardiologist will discuss the risks and benefits with you.

People who have serious symptoms or damage from plaques may need more intervention, such as:

• Special medications ("clot busters") can break up a blockage in an artery.

• Angioplasty (sometimes with stent placement) can open a narrowed or blocked artery.

• Carotid endarterectomy surgically removes plaque from carotid arteries.

• Bypass surgery uses healthy vessels from somewhere else in the body to bypass diseased arteries and restore circulation.

What's the outlook for someone with ASCVD?

That depends on a number of things, including how well they manage risk factors. Treating medical conditions (like high blood pressure) and making lifestyle changes (like quitting smoking) can help reduce the risk of complications like heart attack and stroke. Taking these steps can also reduce the chance of more plaques in people who already have atherosclerosis.

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