3rd June 2026

Diagnosis

The diagnosis of atherosclerosis can be made based on a thorough medical history, including risk factors (family history and lifestyle, etc.), physical examination, blood tests, and imaging.  

History

• Any previous atherosclerotic conditions, e.g., cerebral vascular disease?
• Any risk factors for atherosclerotic disease, e.g., hypertension, smoking
• Family history of any coronary events, especially at a young age.

Clinical examination

• Xanthomata – Yellow raised deposits on the skin, usually around the tendons, knuckles, elbows, and ankles. These are an indication of familial hypercholesterolaemia. 
• Xanthelasma – Yellow raised deposits that appear around the eyelids 
• Corneal arcus – Grey ring that forms around the cornea edge. Associated with ageing, however, if present in younger patients may be a sign of familial hypercholesteremia. 
• Buerger’s test – Tests for arterial insufficiency, which may be present secondary to atherosclerosis. It involves raising the feet of the patient and supporting them at 45-degrees for 2 to 3 minutes. Look for developing pallor to indicate draining of the blood from the peripheries. Then sit the patient up with their legs over the side of the bed, watching for reactive hyperaemia (positive test). The feet will have a delay in return of colour and will be a dusky red. 
• Diminished pulses over the posterior tibial pulse and dorsalis pedis pulse — may indicate PAD.
• Bruits on auscultation of pulses (peripherally, carotids, renal arteries) – may indicate stenosis of arteries 
• Colour changes to peripheries.

Corneal arcus

Image source: Wikimedia Commons (2020), ECG AVNRT, Licenced under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Arcus_Senilis_(cropped).jpg (Accessed: 27 April 2026)

Clinical Manifestations

Atherosclerosis can manifest in different clinical conditions/signs depending on which vessels the deposits are situated in, and how much blood flow is restricted.

• Carotid artery disease – Altered mental status, bruits over carotid arteries, may be asymptomatic until a stroke or TIA occurs. 
• Stroke/ TIA – Sudden onset of neurological symptoms, e.g., hemiparesis or hemisensory symptoms, ataxia, vertigo, altered mental status, vomiting, dysarthria, dysphagia. TIA symptoms completely resolve in 24 hours. 
• Coronary heart disease – chest pain at rest or activity, neck/shoulder/arms/ jaw radiation, dyspnoea, syncope, palpitations
• Peripheral arterial disease – pain on movement in legs and buttocks (usually bilateral but can be unilateral), parasetheisa in legs, hair loss on legs and feet, non-healing ulcers, blue discolouration of feet 
• Mesenteric artery ischaemia – abdominal pain that is acute and severe, usually starting about 30 minutes after eating, nausea, vomiting, diarrhoea. 
• Erectile Dysfunction
• Renal artery stenosis – Hypertension that can be difficult to treat, worsening kidney function, and flash pulmonary oedema.

Investigations

Risk Assessment: 

• Assessment of CVD risk is undertaken depending on previous risk factors. This is followed by a full formal risk assessment if the patient’s estimated 10-year risk of CVD is 10% or more. 
• The QRISK3 tool is used to calculate the estimated CVD risk for people aged between 25 and 84 without existing CVD over the following 10 years. 
  • You cannot use QRISK scores for patients with T1DM, CKD (eGFR <60) or familial hypercholesteremia.

Blood tests: 

• Lipid profile (Total cholesterol, HDL- C, LDL-C, triglycerides) – a non-fasting sample is required
• Non-HDL cholesterol – This can give a more accurate estimate of cardiovascular risk with non-fasting samples
• LFTS – To assess liver function before statin initiation 
• Glucose and HbA1c 
• Renal function (eGFR, creatinine, us&es)  – to assess for reduced renal function secondary to atherosclerosis, for dosing of statins and risk stratification 
• TSH – To exclude hypothyroidism as a secondary cause of hyperlipidaemia 
• Genetic testing of Lipoprotein (a) – may be undertaken if there is a history of familial hypercholesteremia

Imaging: 

• Coronary Artery Disease 
  • Coronary angiography (Gold standard) – especially if intervention (PCI/CABG) is likely 
  • CT Coronary Angiography – Has the benefit of being non-invasive, and is the first-line investigation in outpatient cardiology or chest pain clinics. 
  • CT calcium scoring – A non-invasive test that provides a calcium score regarding the exact location and degree of plaque that is calcified on the coronary arteries. 
  • Stress testing – myocardial perfusion scan, stress echocardiograms  
  • ECG – To look for evidence of a prior MI
• Cerebrovascular Disease
  • Carotid duplex ultrasound – to assess for stenosis in stroke/TIA patients
  • Transcranial Doppler (TCD)  — non-invasive and portable, uses a Doppler transducer to evaluate blood flow within major cranial arteries 
  • CT angiography of carotids for pre-operative planning
  • Non-contrast CT 
  • MRI
• Peripheral Arterial Disease 
  • Ankle-Brachial Pressure Index (ABPI) 
    • Normal: 1-1.4;  PAD <0.9 : Critical limb ischaemia: <0.5 
  • Duplex ultrasound – first line when assessing stenosis 
  • CT angiogram or conventional angiography – when considering revascularisation