You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Is There a Link Between Asthma and Atherosclerotic Cardiovascular Disease?

  • Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 1/13/2023
  • Valid for credit through: 1/13/2024
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, cardiologists, pulmonary medicine specialists, nurses/nurse practitioners, pharmacists, physician assistants and other clinicians who treat and manage patients with asthma.

The goal of this activity is for members of the healthcare team to be better able to analyze the relationship between asthma and atherosclerosis.

Upon completion of this activity, participants will:

  • Assess whether asthma is associated with a higher risk for cardiovascular events
  • Analyze the relationship between asthma and atherosclerosis
  • Outline implications for the healthcare team


Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.

News Author

  • Batya Swift Yasgur, MA, LSW

    Freelance writer, Medscape


    Batya Swift Yasgur, MA, LSW, has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer:

This activity has been peer reviewed and the reviewer has no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.00 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-23-018-H01-P).

    Contact This Provider

  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 01/13/2024. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


Is There a Link Between Asthma and Atherosclerotic Cardiovascular Disease?

Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 1/13/2023

Valid for credit through: 1/13/2024


Clinical Context

Patients living with asthma experience higher levels of chronic inflammation compared with patients without asthma. This inflammation is manifest in chronic respiratory symptoms, but could it also promote higher rates of atherosclerosis and cardiovascular events? The authors of the current study previously addressed this question, using the same cohort of adults from the Multi-Ethnic Study of Atherosclerosis (MESA). The results of their research were published in the June 2015 issue of Arteriosclerosis, Thrombosis, and Vascular Biology.[1]

A total of 6792 adults were followed for a composite of myocardial infarction, stroke, angina, and cardiovascular death for a mean of 9.1 years. The main study variables were intermittent and persistent asthma. Although intermittent asthma was not significantly associated with a higher risk for cardiovascular events, the hazard ratio (HR) for such events associated with persistent asthma was 1.6 (95% CI, 1.01-2.5). This HR was adjusted to account for demographic, disease, and medication variables.

The burden of atherosclerosis on carotid ultrasound is predictive of future cardiovascular events. The current study reexamines the MESA cohort to establish a potential link between asthma and carotid atherosclerosis.

Study Synopsis and Perspective

Persistent asthma is associated with increased carotid plaque burden and higher levels of inflammation, putting these patients at risk for atherosclerotic cardiovascular disease (ASCVD) events, new research suggests.

Using data from the MESA study, investigators analyzed more than 5000 individuals, comparing carotid plaque and inflammatory markers in those with and without asthma.

They found that carotid plaque was present in half of participants without asthma and half of those with intermittent asthma, but in close to 70% of participants with persistent asthma.

Moreover, those with persistent asthma had higher interleukin-6 (IL-6) levels compared with those without asthma or those with intermittent asthma.

“The take-home message is that the current study, paired with prior studies, highlights that individuals with more significant forms of asthma may be at higher cardiovascular risk and make it imperative to address modifiable risk factors among patients with asthma,” lead author Matthew Tattersall, DO, MS, assistant professor of cardiovascular medicine, University of Wisconsin School of Medicine and Public Health, Madison, told | Medscape Cardiology.

The study was published online November 23 in the Journal of the American Heart Association.[2]

Limited Data

Asthma and ASCVD are “highly prevalent inflammatory diseases,” the authors write. Carotid artery plaque detected by B-mode ultrasound “represents advanced, typically subclinical atherosclerosis that is a strong independent predictor of incident ASCVD events,” with inflammation playing a “key role” in precipitating these events, they note.

Serum inflammatory markers such as C-reactive protein (CRP) and IL-6 are associated with increased ASCVD events, and in asthma, CRP and other inflammatory biomarkers are elevated and tend to further increase during exacerbations.

At this time there are limited data looking at the associations of asthma, asthma severity, and atherosclerotic plaque burden, the researchers note, so they turned to the MESA study, a multiethnic population of individuals free of prevalent ASCVD at baseline. They hypothesized that persistent asthma would be associated with higher carotid plaque presence and burden.

They also wanted to explore “whether these associations would be attenuated after adjustment for baseline inflammatory biomarkers.”

Dr Tattersall said that the current study “links our previous work studying the manifestations of asthma,” in which he and his colleagues demonstrated increased cardiovascular events among MESA participants with persistent asthma, as well as late-onset asthma participants in the Wisconsin Sleep Cohort. His group also showed that early arterial injury occurs in adolescents with asthma.[3-5]

However, there are also few data looking at the association with carotid plaque, “a late manifestation of arterial injury and a strong predictor of future cardiovascular events and asthma,” Dr Tattersall said.

He and his group therefore “wanted to explore the entire spectrum of arterial injury, from the initial increase in the carotid media thickness to plaque formation to cardiovascular events.”

To do so, they studied participants in MESA, a study of close to 7000 adults that began in 2000 and continues to follow participants today. At the time of enrollment, all participants were free from CVD.

The current analysis looked at 5029 MESA participants (mean age, 61.6 years; 53% female; 26% Black, 23% Hispanic, 12% Chinese). It compared those with persistent asthma, defined as “asthma requiring use of controller medications”; those with intermittent asthma, defined as “asthma without controller medications”; and those with no asthma.

Participants underwent B-mode carotid ultrasound to detect carotid plaques, with a total plaque score (TPS) ranging from 0 to 12. The researchers used multivariable regression modeling to evaluate the association of asthma subtype and carotid plaque burden.

Interpret Cautiously

Participants with persistent asthma were more likely to be female, have a higher body mass index, and have higher high-density lipoprotein cholesterol levels compared with those without asthma.

Participants with persistent asthma had the highest burden of carotid plaque (P≤.003 for comparison of proportions and P=.002 for comparison of means).

Table 1. Carotid plaque by asthma status

Type of Participant

% With Carotid Plaque

Total plaque score (SD)

No asthma


1.29 (1.80)

Intermittent asthma


1.25 (1.76)

Persistent asthma


2.08 (2.35)

Moreover, participants with persistent asthma also had the highest systemic inflammatory marker levels, both CRP and IL-6, compared with those without asthma. While participants with intermittent asthma also had higher average CRP, compared with those without asthma, their IL-6 levels were comparable.

Table 2. Inflammatory markers by asthma status


No Asthma

Mean (SD)

Intermittent Asthma

Mean (SD)

Persistent Asthma

Mean (SD)

CRP (mg/L)

3.61 (5.50)

4.54 (6.80)

6.49 (11.20)

IL-6 (pg/mL)

1.52 (1.21)

1.60 (1.21)

1.89 (1.61)


In unadjusted models, persistent asthma was associated with higher odds of carotid plaque presence (odds ratio, 1.97; 95% CI, 1.32-2.95), an association that persisted even in models that adjusted for biologic confounders (both P<.01). There also was an association between persistent asthma and higher carotid TPS (P<.001).

In further adjusted models, IL-6 was independently associated with presence of carotid plaque (P=.0001 per 1-SD increment of 1.53), as well as TPS (P<.001). CRP was “slightly associated” with carotid TPS (P=.04), but not carotid plaque presence (P=.07).

There was no attenuation after the researchers evaluated the associations of asthma subtype and carotid plaque presence or TPS and fully adjusted for baseline IL-6 or CRP (P=.02 and P=.01, respectively).

“Since this study is observational we cannot confirm causation, but the study adds to the growing literature exploring the systemic effects of asthma,” Dr Tattersall commented.

“Our initial hypothesis was that it was driven by inflammation, as both asthma and CVD are inflammatory conditions,” he continued. “We did adjust for inflammatory biomarkers in this analysis, but there was no change in the association.”

Nevertheless, Dr Tattersall and colleagues are “cautious in the interpretation,” as the inflammatory biomarkers “were only collected at one point, and these measures can be dynamic--thus, adjustment may not tell the whole story.”

Heightened Awareness

Commenting for | Medscape Cardiology, Robert Brook, MD, professor and director of cardiovascular disease prevention, Wayne State University, Detroit, Michigan, said that the “main contribution of this study is the novel demonstration of a significant association between persistent (but not intermittent) asthma with carotid atherosclerosis in the MESA cohort, a large multiethnic population.”

These findings “support the biological plausibility of the growing epidemiological evidence that asthma independently increases the risk for cardiovascular morbidity and mortality,” added Dr Brook, who was not involved with the study.

“The main take-home message for clinicians is that, just like in [chronic obstructive pulmonary disease] (which is well-established), asthma is often a systemic condition in that the inflammation and disease process can impact the whole body,” he said.

“Healthcare providers should have a heightened awareness of the potentially increased cardiovascular risk of their patients with asthma and pay special attention to controlling their heart disease risk factors (eg, hyperlipidemia, hypertension),” Dr Brook stated.

Dr Tattersall was supported by an American Heart Association Career Development Award. The Multi-Ethnic Study of Atherosclerosis was supported by the National Heart, Lung, and Blood Institute and the National Center for Research Resources. Dr Tattersall and coauthors and Dr Brook have disclosed no relevant financial relationships.

J Am Heart Assoc. Published online November 23, 2022.

Study Highlights

  • The MESA cohort consisted of 6814 healthy participants between the ages of 45 and 84 years. Participants were recruited in 6 distinct geographical areas in the United States, and all participants were free of cardiovascular disease at baseline.
  • The current study focuses on participants who underwent carotid ultrasonography in addition to an assessment of inflammatory biomarkers.
  • Carotid plaque was defined by a focal wall thickening of at least 1.5 cm or a focal thickening at least 50% greater in size than the surrounding intima-media thickness.
  • Asthma was self-reported. Persistent asthma was defined by the regular use of controller medications.
  • The main study outcome was the relationship between asthma and carotid atherosclerosis. This result was adjusted to account for demographic and disease variables, as well as medication use, smoking, and body mass index.
  • 5029 adults provided data for the current analysis; 53% of the cohort were women, and the mean age was 61.6 years. The cohort was diverse in terms of race/ethnicity.
  • 109 participants had persistent asthma and 388 participants had intermittent asthma. They were compared with 4532 adults without asthma (control group).
  • Asthma was more common among women and was associated with higher body mass index, high-density lipoprotein cholesterol levels, and levels of serum IL-6 and CRP.
  • Carotid plaque was present in 50.5%, 49.5%, and 67% of participants with no asthma, intermittent asthma, and persistent asthma, respectively.
  • Intermittent asthma was not associated with a higher risk for carotid plaque in any analysis.
  • However, persistent asthma was associated with an odds ratio for carotid plaque of 1.83 (95% CI, 1.21-2.76) compared with no asthma. Participants with persistent asthma also had a higher total plaque score vs controls.
  • Adjustment for IL-6 and CRP levels did not alter the positive relationship between persistent asthma and the prevalence of carotid plaque.

Clinical Implications

  • A prior study of the MESA cohort found that persistent, but not intermittent, asthma was associated with a significantly higher risk for cardiovascular events.
  • In the current study of the MESA cohort, persistent asthma was associated with a higher rate for carotid plaque in adjusted analysis. Adjustment for IL-6 and CRP levels did not alter the positive relationship between persistent asthma and the prevalence of carotid plaque.
  • Implications for the healthcare team: The healthcare team should work together to reduce cardiovascular risk factors among adults with persistent asthma.


Earn Credit

  • Print