Atherosclerosis in people with diabetes is an important health concern that deserves attention. Prolonged high blood sugar levels can affect blood vessel health and increase the likelihood of fat and cholesterol buildup within the artery walls. Over time, this may lead to narrowing of the arteries and reduced blood flow to various organs, particularly the heart, brain, and limbs. Symptoms do not always appear in the early stages, making regular medical follow-up and control of risk factors especially important. In this article on Dalili Medical, we discuss the causes, symptoms, and types of atherosclerosis in people with diabetes, as well as methods of diagnosis and treatment and the most important tips for preventing its complications.

Does Diabetes Cause Atherosclerosis?

Yes. Diabetes is one of the major risk factors for developing atherosclerosis, particularly when blood sugar levels remain elevated for prolonged periods. However, diabetes is not the only cause of atherosclerosis. Other factors can also increase the risk, including high cholesterol levels, high blood pressure, smoking, and excess body weight.

Does Every Person with Diabetes Develop Atherosclerosis?

No. Developing atherosclerosis is not inevitable for everyone with diabetes. The risk can be significantly reduced by keeping blood sugar levels within the target range, controlling blood pressure and cholesterol, avoiding smoking, following a healthy diet, and engaging in regular physical activity.

Is Atherosclerosis the Same as a Heart Attack?

No. They are different conditions, although they are closely related. Atherosclerosis is a chronic disease in which fatty plaques build up inside artery walls, potentially causing the arteries to narrow or become blocked. A heart attack, on the other hand, is an acute condition that occurs when blood flow to part of the heart muscle is interrupted. Blockage of a coronary artery caused by atherosclerosis is one of the most common causes of a heart attack.

Can Atherosclerosis Exist Without Symptoms?

Yes. Atherosclerosis can develop for a long time without causing noticeable symptoms, especially during its early stages. Symptoms may not appear until the narrowing of the arteries significantly affects blood flow. Therefore, regular medical follow-up and control of risk factors are important for people with diabetes, even when no symptoms are present.

Does High Blood Sugar Alone Cause Atherosclerosis?

No. Prolonged high blood sugar levels increase the risk of blood vessel damage, but high blood sugar is not the only factor that contributes to atherosclerosis. Other factors may also increase the risk, including high levels of low-density lipoprotein (LDL) cholesterol, high blood pressure, smoking, obesity, and physical inactivity.

Can a Cholesterol Test Detect Atherosclerosis?

No. A cholesterol test does not directly diagnose atherosclerosis, but it helps identify one of the major risk factors associated with the disease. Doctors consider cholesterol results along with the patient's medical history, physical examination, and other risk factors to assess the likelihood of atherosclerosis and determine whether treatment is needed.

Do Cholesterol-Lowering Medications Remove Atherosclerosis?

Cholesterol-lowering medications, particularly statins, are used to lower low-density lipoprotein (LDL) cholesterol and reduce the risk of plaque progression and cardiovascular complications. They should not be considered medications that remove all existing plaque from the arteries. Instead, they primarily help slow disease progression and reduce the risk of complications.

Is Atherosclerosis of the Legs Dangerous for People with Diabetes?

Yes. Atherosclerosis affecting the leg arteries can be particularly important in people with diabetes, because reduced blood flow may cause wounds and ulcers on the feet to heal slowly. When poor circulation occurs together with diabetic neuropathy or other diabetes-related foot problems, the risk of complications may increase. For this reason, proper foot care and regular medical follow-up are important.

What Causes Atherosclerosis in People with Diabetes?

Atherosclerosis in people with diabetes is not caused by high blood sugar alone. Rather, it results from a combination of factors that affect blood vessel health. The risk increases with longer diabetes duration, particularly when blood sugar levels and other associated risk factors are not well controlled.

Main Causes and Risk Factors for Atherosclerosis in People with Diabetes

1. Prolonged High Blood Sugar Levels

Chronically elevated blood glucose can gradually damage the lining of blood vessels. It may also increase inflammation and oxidative stress, creating conditions that promote fat buildup and plaque formation inside artery walls.

2. Insulin Resistance

Insulin resistance is particularly common among many people with type 2 diabetes. It is associated with abnormalities in fat metabolism and may affect blood vessel function and increase inflammation, which can contribute to the development of atherosclerosis.

3. Abnormal Blood Lipid Levels

Diabetes may be associated with high triglyceride levels, low levels of good cholesterol (HDL), and changes in low-density lipoprotein (LDL) particles. These lipid abnormalities can increase the likelihood of plaque buildup inside the arteries.

4. High Blood Pressure

High blood pressure places continuous stress on artery walls. When high blood pressure occurs together with diabetes, the risk of blood vessel damage and atherosclerosis may increase.

5. Overweight and Obesity

Excess weight, particularly abdominal fat, is associated with increased insulin resistance, inflammation, abnormal lipid levels, and high blood pressure. These factors may increase the risk of cardiovascular disease.

6. Smoking

Smoking damages the lining of blood vessels, increases inflammation, affects normal artery function, and increases the likelihood of blood clot formation. The risk can be even greater when smoking occurs together with diabetes.

7. Chronic Inflammation

Obesity, diabetes, and certain metabolic disorders may be associated with a state of low-grade chronic inflammation. Inflammation can contribute to the formation and progression of plaques within artery walls.

8. Diabetes-Related Kidney Disease

Diabetes can lead to chronic kidney disease, which is itself associated with an increased risk of cardiovascular disease. Therefore, kidney problems in a person with diabetes are an important factor when assessing the risk of atherosclerosis.

9. Physical Inactivity

A sedentary lifestyle can contribute to weight gain, insulin resistance, high blood pressure, and abnormal lipid levels. As a result, physical inactivity may increase several risk factors associated with atherosclerosis.

10. Older Age and Longer Duration of Diabetes

The risk of atherosclerosis increases with age. In addition, having diabetes for a longer period means that blood vessels may be exposed to diabetes-related risk factors for a longer time, particularly when blood sugar is not well controlled.

11. Genetic Factors and Family History

Having a family history of heart disease or atherosclerosis may increase a person's susceptibility to the condition. Certain inherited disorders that affect cholesterol levels can also increase the risk of plaque buildup in the arteries.

12. Poor Control of Associated Risk Factors

Persistently elevated blood sugar, blood pressure, or cholesterol levels can contribute to the progression of arterial disease. Failure to follow the treatment plan prescribed by a healthcare professional may also make these risk factors more difficult to control.

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Symptoms of Atherosclerosis in People with Diabetes

Atherosclerosis in people with diabetes may develop without noticeable symptoms, particularly in its early stages. This is because narrowing of the arteries can occur gradually before it significantly affects blood flow. Symptoms vary depending on which arteries are affected, as well as the location and severity of the narrowing.

1. Symptoms of Coronary Artery Atherosclerosis

When atherosclerosis affects the coronary arteries, which supply blood to the heart muscle, symptoms may include:

• Pain, pressure, or heaviness in the chest, particularly during physical activity.
• Shortness of breath, especially during exertion.
• Feeling unusually tired or fatigued.
• Pain or discomfort that may spread to the arm, shoulder, back, neck, or jaw.
• Dizziness or nausea.
• Increased sweating in some cases.

It is important to note that symptoms of reduced blood flow to the heart may be less noticeable in some people with diabetes, and typical chest pain may sometimes be absent because of nerve damage affecting pain sensation. Therefore, the absence of chest pain does not necessarily mean that there is no problem with the coronary arteries.

2. Symptoms of Carotid and Cerebral Artery Atherosclerosis

When atherosclerosis affects the arteries that supply blood to the brain, neurological symptoms may occur suddenly, including:

• Sudden weakness or numbness in the face, arm, or leg, especially on one side of the body.
• Sudden difficulty speaking or understanding speech.
• Sudden changes or disturbances in vision.
• Severe dizziness or loss of balance and coordination.
• A severe, sudden headache in some cases.

These symptoms may indicate a transient ischemic attack (TIA) or stroke and require immediate medical attention.

3. Symptoms of Leg Artery Atherosclerosis

When atherosclerosis affects the arteries of the lower limbs, a person may experience:

• Pain or cramping in the leg muscles when walking, which usually improves after stopping and resting.
• A feeling of heaviness or fatigue in the legs during walking.
• Cold feet, with one foot sometimes feeling colder than the other.
• Changes in the color of the skin of the foot or leg.
• Weak pulses in the foot.
• Slow healing of wounds and ulcers on the feet.
• Slower hair or toenail growth in the affected limb in some cases.

In advanced cases, leg pain may occur even at rest, or ulcers that are difficult to heal may develop.

These symptoms are particularly important in people with diabetes because reduced blood flow may occur together with diabetic neuropathy and other foot problems, making injuries more difficult to notice and manage.

4. Symptoms of Renal Artery Atherosclerosis

Narrowing of the renal arteries often does not cause noticeable symptoms during its early stages. When the narrowing significantly affects blood flow, it may be associated with:

• Difficulty controlling high blood pressure.
• Unusually high blood pressure or worsening blood pressure control.
• Declining kidney function in some cases.

It is important to distinguish between renal artery atherosclerosis and diabetic kidney disease, as they are different conditions, although they can occur in the same person.

Can Atherosclerosis Occur Without Symptoms?

Yes, and this is particularly important for people with diabetes. Atherosclerosis may be present for a long time without obvious signs, with symptoms appearing only when the narrowing becomes significant enough to affect blood flow.

In summary: The symptoms of atherosclerosis in people with diabetes vary according to the affected arteries. Coronary artery disease may cause chest pain and shortness of breath; carotid and cerebral artery disease may cause sudden neurological symptoms; leg artery disease may cause pain during walking and poor circulation; while renal artery narrowing may not cause obvious symptoms in its early stages.

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Types of Atherosclerosis in People with Diabetes

Atherosclerosis in people with diabetes is not limited to one type. It can affect different arteries throughout the body. Its effects depend on the location and severity of the arterial narrowing. Some people with diabetes may have atherosclerosis affecting more than one vascular region at the same time.

1. Coronary Artery Atherosclerosis

This occurs when fatty plaques build up inside the coronary arteries, which supply blood and oxygen to the heart muscle.

Narrowing of these arteries may lead to:

• Coronary artery disease.
• Angina.
• Reduced blood flow to the heart muscle.
• A heart attack when an acute blockage occurs in a coronary artery.

Coronary atherosclerosis is one of the most important forms of atherosclerotic disease in people with diabetes because they have an increased risk of cardiovascular disease.

2. Carotid and Cerebral Artery Atherosclerosis

Atherosclerosis can affect the carotid arteries or other arteries that supply blood to the brain.

Severe narrowing or blockage of these arteries can reduce blood flow to the brain and may cause:

• A transient ischemic attack (TIA).
• Stroke.
• Weakness or numbness on one side of the body.
• Difficulty speaking or understanding speech.
• Vision problems.
• Problems with balance or movement.

Sudden neurological symptoms require urgent medical evaluation.

3. Atherosclerosis of the Lower Extremities

When atherosclerosis causes narrowing of the arteries supplying the legs, it is commonly referred to as peripheral artery disease (PAD).

Possible symptoms include:

• Pain or cramping in the leg when walking that improves with rest.
• Tiredness or heaviness in the legs.
• Cold feet.
• Weak pulses in the feet.
• Changes in skin color.
• Slow healing of wounds and ulcers.

This condition is particularly important in people with diabetes because reduced blood flow may occur together with diabetic neuropathy and foot problems, potentially making injuries more difficult to detect and wounds more difficult to heal.

4. Renal Artery Atherosclerosis

This occurs when the arteries supplying blood to the kidneys become narrowed.

It may be associated with:

• High blood pressure or difficulty controlling it.
• Reduced kidney function in some cases.

It is important to distinguish renal artery atherosclerosis from diabetic kidney disease. They are different conditions, although they can occur together.

5. Atherosclerosis of the Large Arteries

Atherosclerosis can also affect large arteries, such as the aorta and other major arteries throughout the body.

The risk may increase when diabetes occurs together with other risk factors, such as high blood pressure, high cholesterol, and smoking.

6. Multivessel Atherosclerosis

In some people with diabetes, atherosclerosis may not be limited to one area. It can affect several vascular regions at the same time, such as:

Coronary arteries + carotid arteries + leg arteries.

The presence of atherosclerosis in multiple vascular regions may indicate widespread atherosclerotic disease and highlights the importance of comprehensive assessment and management of cardiovascular risk factors.

Diagnosis of Atherosclerosis in People with Diabetes

The diagnosis of atherosclerosis in people with diabetes does not depend on a single blood test or examination. Instead, it involves a combination of medical history, physical examination, assessment of risk factors, and appropriate diagnostic tests based on the patient’s symptoms and the suspected location of arterial narrowing or blockage.

Atherosclerosis may also be present without obvious symptoms, so doctors pay attention to the overall risk of cardiovascular disease in people with diabetes.

1. Medical History

The doctor begins by evaluating symptoms and factors that may indicate reduced blood flow, including:

• Chest pain, pressure, or heaviness, particularly during physical activity.
• Shortness of breath or fatigue during activity.
• Leg pain or cramping while walking that improves with rest.
• Cold feet or changes in skin color.
• Slow-healing wounds or ulcers on the feet.
• Sudden weakness or numbness on one side of the body.
• Sudden difficulty with speech or vision.

The doctor may also ask about several risk factors, such as:

• How long the patient has had diabetes and how well blood glucose is controlled.
• High blood pressure.
• High cholesterol or triglyceride levels.
• Smoking.
• Weight and level of physical activity.
• A family history of heart or vascular disease.

2. Physical Examination

The doctor may perform an examination of the heart and circulatory system, which can include:

• Measuring blood pressure.
• Checking the pulse in the arteries of the arms and legs.
• Listening for abnormal sounds over certain arteries.
• Examining the feet and skin for changes in color and temperature.
• Looking for wounds, ulcers, or signs of poor circulation.

This examination helps determine whether additional testing is needed.

3. Blood Tests

Blood tests cannot directly diagnose atherosclerosis, but they can help identify factors that increase the risk of developing it. These may include:

• Blood glucose testing.
• Hemoglobin A1c (HbA1c) to assess average blood glucose levels over the previous several months.
• Lipid profile, including LDL cholesterol, HDL cholesterol, triglycerides, and total cholesterol.
• Kidney function tests when risk factors or suspected kidney disease are present.

4. Ankle-Brachial Index (ABI)

The ankle-brachial index (ABI) is particularly useful when peripheral artery disease in the legs is suspected.

The test compares blood pressure at the ankle with blood pressure in the arm and can help assess blood flow to the lower limbs.

However, in some people with diabetes, the arteries may become calcified and difficult to compress normally, which can make the ABI result less reliable. In such cases, the doctor may recommend additional tests.

5. Ultrasound and Doppler Examination

Vascular ultrasound with Doppler can be used to assess blood flow through the arteries and identify areas of narrowing or blockage.

Examples include:

• Carotid artery Doppler ultrasound.
• Leg artery Doppler ultrasound.

This is a non-invasive examination and usually does not require instruments to be inserted into the blood vessels.

6. Electrocardiogram and Cardiac Tests

When symptoms or other findings suggest possible coronary artery disease, the doctor may request tests such as:

• Electrocardiogram (ECG).
• Exercise stress testing when appropriate.
• Echocardiography.
• Other cardiac imaging tests depending on the patient’s condition.

These tests help evaluate heart function and possible reduced blood flow to the heart muscle. However, none of these tests alone necessarily confirms the presence of atherosclerosis.

7. CT Angiography and Other Vascular Imaging

When the doctor needs more detailed information about the location, severity, and extent of arterial narrowing, additional imaging may be performed, including:

• CT angiography (CTA).
• Magnetic resonance angiography (MRA).
• Catheter-based angiography in selected cases, particularly when detailed assessment of the arteries or planning for an intervention is required.

The choice of test depends on the patient’s symptoms, suspected location of disease, and overall health.

8. Evaluation of the Coronary Arteries in People with Diabetes Without Symptoms

Having diabetes does not automatically mean that every patient needs coronary artery imaging or an exercise stress test simply to screen for atherosclerosis.

In people without symptoms, the decision to perform advanced cardiovascular testing is based on the patient’s overall cardiovascular risk, other risk factors, clinical examination, and results of the initial evaluation.

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Medical Treatment of Atherosclerosis in People with Diabetes

Treatment of atherosclerosis in people with diabetes does not rely on a single medication. The goals are to reduce the risk of cardiovascular complications, slow disease progression, and control factors that can damage the arteries, such as high blood glucose, high cholesterol, and high blood pressure.

The appropriate treatment is determined according to the patient’s age, type of diabetes, location of atherosclerosis, presence of heart or vascular disease, cholesterol and blood pressure levels, kidney function, and other health factors.

1. Cholesterol-Lowering Medications

Statins are among the most important medications used to reduce the risk of cardiovascular complications in many people with diabetes, particularly when additional risk factors or established arterial disease are present.

Examples include:

• Atorvastatin.
• Rosuvastatin.
• Simvastatin.

These medications lower LDL cholesterol, helping reduce the risk of plaque progression and complications associated with atherosclerosis.

If the desired LDL level is not reached with a statin alone, the doctor may add another medication such as ezetimibe. In some patients at very high cardiovascular risk, PCSK9 inhibitors may also be considered.

2. Diabetes Medications

Good blood glucose control is an important part of reducing diabetes-related vascular complications.

The choice of diabetes medication depends on the patient’s individual condition. Some medications may provide cardiovascular and kidney benefits in certain people with type 2 diabetes, including:

• SGLT2 inhibitors.
• GLP-1 receptor agonists.

This does not mean that every person with diabetes and atherosclerosis needs one of these medications. The choice depends on the patient’s health, other medications, kidney function, and other factors.

3. Medications for High Blood Pressure

If a person with diabetes has high blood pressure, controlling it can help reduce the risk of cardiovascular and cerebrovascular complications and protect the blood vessels.

Depending on the patient’s condition, the doctor may prescribe:

• Angiotensin-converting enzyme (ACE) inhibitors.
• Angiotensin II receptor blockers (ARBs).
• Calcium channel blockers.
• Diuretics.
• Other medications when needed.

The choice of medication depends on blood pressure levels, kidney function, associated medical conditions, and other medications being taken.

4. Antiplatelet Medications

Medications such as:

• Aspirin.
• Clopidogrel.

may be used in some patients.

These medications reduce platelet aggregation and can be appropriate for certain people with established arterial disease, such as those with a previous heart attack, stroke, or peripheral artery disease.

However, aspirin should not be taken simply because a person has diabetes or risk factors for atherosclerosis. It can increase the risk of bleeding, so the decision should be made by a doctor after carefully weighing the potential benefits and risks.

5. Medications for Symptoms of Peripheral Artery Disease

When atherosclerosis causes peripheral artery disease and produces leg pain during walking, certain medications may be prescribed to improve walking ability in selected patients.

One example is cilostazol, although it is not suitable for everyone and should not be used in people with heart failure.

6. Can Medications Completely Remove Atherosclerosis?

Atherosclerosis medications should not be considered a guaranteed way to remove all existing plaques from the arteries.

Instead, medical treatment focuses on controlling risk factors, slowing disease progression, and reducing the risk of heart attacks, strokes, blood clots, and other cardiovascular complications.

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Surgical Treatment of Atherosclerosis in People with Diabetes

Not every person with diabetes and atherosclerosis requires angioplasty, stenting, or surgery. In many cases, the condition can be managed with medications, lifestyle changes, and control of blood glucose, cholesterol, and blood pressure.

Interventional procedures or surgery may be considered in selected cases, such as severe arterial narrowing, significant symptoms, or inadequate blood flow that threatens the heart, brain, or a limb.

The type of intervention depends on the location of the disease, such as the coronary arteries, carotid arteries, or leg arteries.

1. Coronary Angioplasty and Stenting

Percutaneous coronary intervention (PCI) may be used to treat certain cases of coronary artery narrowing, particularly when the narrowing significantly affects blood flow or causes symptoms or reduced blood supply to the heart muscle.

How Is Angioplasty Performed?

• The doctor inserts a thin tube called a catheter into an artery, usually through the wrist or groin.
• The catheter is guided toward the coronary arteries using X-ray imaging.
• A contrast dye is injected to help identify the location and severity of the narrowing.
• A small balloon may be passed to the narrowed area and inflated to improve blood flow.
• A stent may be placed inside the artery to help keep it open.

Angioplasty is generally less invasive than coronary artery bypass surgery, but its suitability depends on the location, severity, and number of blockages, as well as the patient’s overall health.

2. Coronary Artery Bypass Grafting (CABG)

Coronary artery bypass grafting (CABG) may be appropriate in certain cases of coronary artery disease, particularly when there are multiple or severe blockages or when angioplasty is not the most suitable option.

How is it performed?

The surgeon uses a suitable blood vessel from another part of the patient’s body, such as an artery from the chest or a vein from the leg, to create a new route that allows blood to reach the heart muscle around the narrowed or blocked section of the coronary artery.

This surgery may be an appropriate option for some people with diabetes who have multivessel coronary artery disease. However, the decision depends on coronary angiography findings, heart function, and the patient’s overall health.

3. Leg Artery Angioplasty

When there is severe narrowing in the arteries of the lower limbs, an endovascular procedure may be used to improve blood flow to the leg.

The procedure may involve:

• Balloon angioplasty to widen the narrowed artery.
• Placement of a stent in selected cases.
• Other endovascular techniques to remove or reduce the blockage, depending on its location and characteristics.

After the procedure, the patient generally needs to continue prescribed medications and control cardiovascular risk factors to reduce the risk of disease progression or recurrence.

4. Leg Artery Bypass Surgery

If the blockage is long or severe, or if angioplasty is not appropriate, the doctor may consider leg artery bypass surgery.

During the procedure, a new route for blood flow is created using a suitable blood vessel from the patient’s body or a synthetic graft. This new route bypasses the narrowed or blocked section of the artery.

This type of intervention may be considered when there is:

• Severe pain caused by inadequate blood flow.
• Wounds or ulcers that fail to heal because of poor circulation.
• Severe limb ischemia that threatens the limb.

5. Plaque Removal from an Artery

In selected cases of peripheral artery disease, a procedure called endarterectomy may be performed.

During this procedure, the surgeon opens the artery and removes the plaque buildup from inside the artery to improve blood flow, after which the artery is closed.

The procedure is used in selected cases, and the decision depends on the location and severity of the blockage, the characteristics of the plaque, and the patient’s overall health.

6. Carotid Endarterectomy

When there is significant narrowing of the carotid artery that supplies blood to the brain, carotid endarterectomy may be appropriate for certain patients, particularly in situations where the risk of stroke is considered high.

How is it performed?

• The surgeon makes an incision to access the carotid artery.
• The plaque buildup inside the artery is removed.
• The artery is closed to restore appropriate blood flow.

Carotid artery stenting may be an alternative to surgery for selected patients. The doctor determines the most appropriate option based on the degree and location of the narrowing, the presence of symptoms, and the risks associated with each procedure.

Can Angioplasty or Surgery Cure Atherosclerosis?

No. Angioplasty and surgery are intended to improve blood flow and treat narrowing or blockage in the targeted artery, but they do not eliminate the underlying process of atherosclerosis throughout the body.

Therefore, even after successful angioplasty or surgery, a person with diabetes should continue to:

• Control blood glucose levels.
• Manage cholesterol according to the prescribed treatment plan.
• Control blood pressure.
• Avoid smoking.
• Take prescribed medications as directed.
• Follow a heart-healthy lifestyle.
• Attend regular medical follow-up appointments