Anyone diagnosed with atherosclerosis/heart disease, who has had a heart attack, stroke, a bypass or a stent, or indeed anyone who has had any kind of heart problem due to plaque in their arteries, will surely have asked themselves this question.
We're told by the NHS and the BHF that we can't remove plaque from our arteries, but what about new plaque? Are our medication and life style choices preventing new plaque being formed, or are our arteries getting worse over time?
I've always thought that, apart from some serious investigative work like an angiogram, we'll never know the answer.
But some remarkable research gives us a tool that, even though it's far from the complete answer, at least gets us a bit closer to addressing that question. And what's more it uses an often ignored part of the blood test that most of us already have from the annual cardio check-up with our GP's.
If you dig out your blood test you'll find a score for HbA1c, or Haemoglobin A1c. It will be a number, such as 29 mmol/mol, or 48 mmol/mol. It's a measure of how much glucose (sugar) has stuck to our red blood cells. It's a useful measure because it doesn't require us to have fasted before the blood test, indeed it's really an average showing how our bodies have processed the sugar and carbs that we've eaten over the previous few months.
If that number is 42 or above your GP may warn you that you're pre-diabetic, and if that number is over 48 your doctor may refer you to an NHS Diabetes Prevention programme, or perhaps prescribe some additional medication.
But if that number is below 42 the most likely thing is that your GP will just ignore it.
I recently came across a very large piece of high quality research that basically asks, is there a relationship between our HbA1c scores and the amount of plaque being formed in our arteries?
And the answer is a resounding yes. As the graph at the beginning of this post shows, the higher our HbA1c scores then the more plaque is being formed.
Couple of things that may help you understand this graph.
Firstly, there are different ways of stating HbA1c scores, this research uses % scores instead of the mmol/mol scores. But they're easy to translate, for example the very low 4.8% in the above graph is equal to 29mmol/mol, and the very high 6.1% is equal to 43mmol/mol. You can translate your score from mmol/mol to % using the following tool, so you can exactly where you personally fit on this graph,
The second thing to understand is that the research draws a distinction between no plaque (disease) at all, finding an isolated example of plaque, and finding lots of plaque in multiple locations across different arteries. That's the meaning of the "no disease, focal, intermediate, generalised" scores.
What we can clearly see is that the higher our HbA1c scores then the more likely that new plaque is being formed in our arteries.
But unless our HbA1c scores are 42 or over our doctors are unlikely to discuss this with us. And that's a shame as there are plenty of things, from life style to medication, that most of us can do to bring our HbA1c scores down. I've gone from low 40's to low 30's with weight loss, exercise, and a healthier diet, and what's more I've kept it there for nearly five years. But armed with this research I'm asking myself if I can't go further, maybe I can tweak my diet, weight and exercise regime a bit more and see if I can get back to HbA1c scores in the high 20's?
The research concludes that HbA1c scores are so significant they should be added to the statistical tools that our GP's use to predict our risk of heart attacks and strokes. Furthermore the research says that GP's should discuss with their patients, at much lower HbA1c scores, that if they make different life style choices or possibly consider medication such as metformin, then they can probably reduce their HbA1c scores and in doing so reduce their risks of angina, heart attacks, and strokes.
That all makes perfect sense to me, but I guess with our overworked NHS it's down to us to educate ourselves and change our life styles without waiting for a prod from our GP's.
If you want to read the original research in full you can download the pdf here,
Thanks Chappychap ..great finding quite interesting as well. I always had very low sugar level prior to stents. Since I started my statin I exercise more, eat even better my sugar jumped to 5.4 fasting and recently back to 5.0 .I feel statin or other medicine may have caused this. I don't know what to make up my situation based on this finding. Anyway good read and thanks for sharing
All I can say is that my Hb1Ac has slowly crept up over the years and I am now on the verge of being pre-diabetic. I have put that down to long term use of atorvastatin where there is a potential link to diabetes, see below, and also possibly age related factors. But in my case long term statin use remains my priority. Finally I had a recent angiogram some five years after an NSTEMI which showed little difference between the two, which may be some indication that continuing plaque lay down for me may not be significant, if at all.
I agree that the science is clear, for a small number of people statins can trigger a problematic glucose response.
But it's important to keep a sense of perspective. Something like 400 or 500 people would need to take statins in order for just one of them to contract T2 diabetes.
On the other hand, in order to be prescribed statins a patient in the UK would need a poor score on a predictive statistical tool like QRisk3. According to QRisk3 the typical middle aged male would have about a 6-10% chance of a heart attack or stroke in the next ten years, but to be prescribed statins this would typically require additional risk factors that would take their chances to 15% or above. That's pretty close to one in six, or a roll of the dice. For many people on this forum their odds are worse than one in two, or a flip of the coin.
Faced with those odds I'd much rather take the proven benefits of a statin, even if that did bring an additional one in four hundred chance of T2 diabetes.
And that I think is the really important element of your post.
In the real world our health problems often require trade-offs. Accepting some risks in order to mitigate others. Dealing with unpleasant side effects or making difficult life style choices in order to potentially buy ourselves additional years of active, healthy life.
Where we strike that balance is our personal choice. But the starting point for making choices that are right for us as individuals is to have as much objective information as possible.
There are no guarantees, but the evidence shows that with enough application you've a good chance of getting there! My sister was diagnosed with full blown T2 diabetes, but she managed to get her HbA1c scores right down and is now free from all her diabetes meds. It wasn't easy, but the life she lives today is incomparably better than where she was.
That's a really interesting article, thanks. Must admit I'm a bit worried now as I've looked at some of my blood results from May last year when I went to A&E with chest pains. I had been on 80mg of atorvastatin since December 2021, so just over 5 months. My HbA1c was 42. Nothing was mentioned about this number being high.
I'm now on 40mg of statins, had a full blood test about 2months ago, (cholesterol was ok but cannot remember the other results) and due to a very recent move cannot yet access my full patient record .
Since my HA in December 2021 I've lost some weight and been eating quite healthy, cutting out a lot of fat and sugar, but as I mentioned in another post a while ago am still worried about sugar levels in food.
Meanwhile, any tips on reducing even further my sugar intake please until I can access my results?
Hello Lily. I sympathise. Modern life makes it extraordinarily difficult to eat healthily. Processed food is cheap, tasty and convenient, so rejecting it is really, really tough.
It's also shocking just how much sugar gets smuggled into our diets. Looking at the small print even savoury things are stuffed with sugar, or with the highly processed carbs that our bodies instantly turn into sugar.
I wish there were simple solutions, but if there are I've never found them.
It's more about staying vigilant and hoping that, bit by bit, our good choices outweigh our mistakes.
One thing to remember, every time we reach for a healthy alternative we're saving ourselves from a damaging glucose spike. So one bottle of beer rather than two, or an apple instead of a slice of cake, or a salad in place of a pizza.
Each and every one of these small victories counts.
Every time you go from meal to meal without snacking in between, or every time you take the stairs instead the lift, you're getting rid of excess sugar from your bloodstream and giving your cells a chance to recover their youthful sensitivity to insulin. The challenge may seem overwhelming, but every little win brings health benefits.
Excellent article! However, I cannot check where I am with this as none of my blood tests show HbA1c results. This must be a local thing (Northampton)... or maybe I'm just not a concern.
When discussing my options with my surgeon before my bypass op, he did suggest that I would be acquiring new plaque as he gave me 25 years before further intervention if I had the op and 10 years if I just had stents. There was no mention of how to slow the process beyond a good lifestyle, exercise and statins to keep what plaque I already had stable.
Chappychap, this is a very interesting post and food for thought. I downloaded both the A1C conversion tool and the research article to try to slough through later today. It is the wee hours here so too tired to think too heavily at this time.
I would love to lower my A1c score, but it sounds like I need to get very serious about it all. When I was young, I never understood the connection between blood glucose levels and heart disease. I guess that I thought of them as separate items/concerns that I put in separate boxes in my mind. Plus, my doctors never helped me to see those relationships, or connections. After my HA last year, I started doing a lot of reading on my own to try to learn more about the role of T2 diabetes and heart disease.
At the time of my HA last March, my A1c % was 6.6 (high)—in diabetic range. I was retested in February 2023 (Valentine’s Day) and my A1c % was 6.2. That is still high, but I think that it is back into prediabetic range. I have actually been in the prediabetic range for years, which I guess is considered “controlled” since it is below 7%. I have always refused medication and, if I am honest, I refuse to accept that I am prediabetic/diabetic. This is a work in progress for me, but if you and others can lower your A1c, then perhaps there is hope for me too.
When I was in the hospital with the HA, the assigned cardiologist didn’t really talk with me, or try to explain anything. He just prescribed 80 mg of Atorvastatin, told me that I had calcifications/blockages, ordered a nuclear stress test, and prescribed metformin. My head was reeling. To me, the HA was totally unexpected—no one explained anything—and I had new drugs to take.
I had to see my GP within one week of being in the hospital so I talked with her about the drugs. We changed the Atorvastatin to 20mg and we decided to not take the metformin yet. It was controlled (below 7%) so we would see if diet and other changes would bring the A1c levels down. In May, I saw a new cardiologist and we increased the Atorvastatin to 40mg, which seems to be working for me. She also increased my beta blocker to 75 mg daily and that has also helped. I am still not taking the metformin. I did see a small decrease in A1c by Feb. (6.6% to (6.2%).
I apologize for rambling on, but your post really has me thinking about all of this. As I stated earlier, I never realized the connection between A1c scores and heart attacks. I just saw them as separate things—not possibly cause and effect. Now, the article that you mentioned seems to suggest that A1c percentages might be a risk factor and/or potential predictor of HA.
Anyway, thank you for the article to read and digest, and for making me get more serious again about diet and exercise in lowering my A1c. It seems that I never have any answers—just more questions.
Hi Chappychap. Thanks for the link I will read that in more depth later. Reading quickly through your message has made me want to look into this more. My atherosclerosis/Atheroma is 5 generations family linked and only just being linked to cholesterol. I was put on statins just pre OH triple by pass in 2015 and within months was diagnosed with pre-diabetes. However following a SCA 6 months ago I was taken off statins while in hospital and came home with no supply so 2 months without medication and all of a sudden a routine GP blood test for my blood sugar came back totally normal but was advised cholesterol had shot up. For all my 68 years my weight has been very good, diet good with little/low cholesterol foods eaten and lifestyle got very altered following OH nearly 10 years ago now. I am very interested to know if there is any research done or currently being done into this sort of situation. As the current cholesterol/plaque readings and presumably accumulating in my arteries, I don’t believe is from my diet or lifestyle, in fact there is nothing more I can do to alter those and gave up smoking pre OH but cholesterol higher now than then even. If you know or hear of any published papers or research I would very interested. Consultant is trying new injection type med instead of statin so hoping this will work and lower cholesterol but not increase blood sugar. Take care 🙂
I'm normally a bit sceptical about genetic causes for heart disease, the truth is that there's very blurred lines between genetic explanations and life style explanations. And many families have shared life styles just as much as shared genes!
But high persistently cholesterol is the exception.
The NHS must think so too, because it's the one heart related condition where they'll authorise DNA testing. What they're looking for is the genes that cause Familial Hypercholesteraemia.
The good news is that there are some very effective new medication, such as Inclisiran, that's proving incredibly effective in lowering cholesterol amongst even the most resistant patients.
Yes a line of enquiry my consultant and I have briefly touched on. Although he is more concerned with treating me than looking at past . My father died at 39 having been a member of post war Olympic swimming team and a health food devotee. His Mother had died when he was 12 and prior generations died at similar young ages of same atheroma diagnosis. My daughter is currently undergoing breast cancer treatment and is on clinical trail for new drug that is less heart toxic and being monitored by St Thomas’s due to my history and family history. They have mentioned us having blood tests along with my sisters for familiar connections. Current trying Alirocumab fortnightly injections for cholesterol as either not been able to tolerate statin or they have been ineffectual. Thanks again for the info on medication and will take that to my next appointment. Stay Well x
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vasospastic coronary arteries
I HAVE INHERITED CORONARY ARTERY DISEASE 
They can't find anything, but it's getting worse.
Should we be warned if they see we getting worse 
Calcium and arteries 
