Patients with atherosclerotic cardiovascular disease (ASCVD) are often managing more than just elevated cholesterol. In addition to plaque buildup in the arteries, many patients also have a high coronary artery calcium score, elevated hemoglobin A1C, hypertension, or high triglycerides.
Even when patients take a statin and successfully lower LDL cholesterol and ApoB, these additional metabolic and inflammatory risk factors can continue to influence cardiovascular risk and long-term outcomes.
Chronic low-grade inflammation plays a central role in plaque development, progression, and instability, even in patients with well-controlled LDL levels. According to the 2025 scientific statement from the American College of Cardiology, inflammation is a key contributor to cardiovascular disease and remains an important therapeutic target in high-risk patients (Mensah et al., 2025). The ACC’s 2025 nutrition guidance also emphasizes that dietary patterns can significantly influence inflammatory pathways and overall cardiovascular risk (Williams et al., 2025).
The Link Between Inflammation and Cardiovascular Disease
Inflammation is the body’s natural immune response to injury or infection. In the short term it is protective. However, when inflammation becomes chronic and low grade, it can damage blood vessels and accelerate the development of atherosclerosis.
Diets high in refined carbohydrates, added sugars, processed meats, and saturated fats stimulate the production of pro-inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. These inflammatory signals impair endothelial function, worsen insulin resistance, increase triglyceride production, and raise blood pressure.
Over time, this metabolic and inflammatory environment promotes plaque growth and increases the likelihood of heart attack and stroke (Mensah et al., 2025).
The inflammatory potential of diet has been quantified using tools such as the Empirical Dietary Inflammatory Pattern index. In large prospective cohorts involving more than 200,000 men and women in the United States, individuals consuming more pro-inflammatory diets had significantly higher cardiovascular disease risk, while those following anti-inflammatory dietary patterns had lower risk (Li et al., 2020).
These findings show that diet quality directly influences inflammation and long-term heart health.
What Is an Anti-Inflammatory Diet?
Anti-inflammatory diets focus on whole, minimally processed foods that help reduce inflammatory signaling and improve metabolic health.
One of the best studied examples of an anti-inflammatory eating pattern is the Mediterranean diet.
This dietary pattern emphasizes:
- Fruits
- Vegetables
- Whole grains
- Legumes
- Nuts
- Extra virgin olive oil
- Fatty fish rich in omega-3 fatty acids
It also limits refined carbohydrates, sugar-sweetened beverages, processed meats, and excess saturated fat.
Reviews of anti-inflammatory dietary patterns demonstrate consistent reductions in inflammatory biomarkers such as C-reactive protein and interleukin-6, along with improvements in insulin sensitivity and lipid profiles (Yu et al., 2024; Hornero-Ramirez et al., 2023; Reyneke et al., 2025).
Because of these combined metabolic and inflammatory benefits, anti-inflammatory dietary patterns are increasingly recommended as part of comprehensive cardiovascular disease prevention strategies.
Mediterranean Diet and Cardiovascular Outcomes
The cardiovascular benefits of the Mediterranean diet are supported by several landmark randomized trials.
In high-risk patients, the PREDIMED trial demonstrated that a Mediterranean diet supplemented with extra virgin olive oil or nuts significantly reduced major cardiovascular events compared with a low-fat diet (Mensah et al., 2025).
Similarly, the Lyon Diet Heart Study reported up to a 65 percent reduction in cardiac death and nonfatal myocardial infarction among participants assigned to a Mediterranean-style diet (Virani et al., 2023).
Importantly, these benefits were observed in patients who were already receiving contemporary medical therapy, including lipid-lowering medications. This highlights an important concept in preventive cardiology: Diet addresses residual inflammatory and metabolic risk that medications alone may not fully correct.
Omega-3 Fatty Acids and Inflammation Resolution
Fatty fish such as salmon, sardines, and mackerel provide EPA and DHA, which are incorporated into cell membranes and converted into specialized pro-resolving mediators.
These compounds help actively resolve inflammation rather than simply suppress it.
Higher plasma levels of EPA and DHA have been associated with 27 to 49 percent lower cardiovascular mortality and reduced risk of nonfatal myocardial infarction (Mensah et al., 2025).
A dose-dependent relationship has also been observed, with each additional gram per day of EPA plus DHA associated with lower myocardial infarction and total coronary heart disease risk (Mensah et al., 2025).
The ACC recommends two to three servings of fatty fish per week as part of a heart-healthy anti-inflammatory diet (Williams et al., 2025).
In contrast, the 2023 guideline for chronic coronary disease notes that non-prescription omega-3 supplements and antioxidant vitamins have not consistently reduced acute cardiovascular events, underscoring the importance of whole-food dietary patterns (Virani et al., 2023).
That said, omega-3 fatty acid supplementation can still improve certain cardiometabolic biomarkers. Increasing EPA and DHA intake raises the omega-3 index in cell membranes, lowers triglycerides, and may help shift the balance between omega-3 and omega-6 fatty acids toward a less inflammatory profile. For this reason, optimizing omega-3 intake remains a common strategy for improving cardiometabolic health, even though whole food sources such as fatty fish are generally preferred (Mensah et al., 2025).
Why Anti-Inflammatory Eating Matters in High CAC, High A1C, and Hypertension
Patients with high coronary artery calcium scores already have established atherosclerosis.
Elevated A1C reflects insulin resistance, which is closely linked to inflammation and increased triglyceride production. Refined sugars stimulate hepatic de novo lipogenesis, converting excess carbohydrates into triglycerides and contributing to dyslipidemia (Williams et al., 2025).
Hypertension is also associated with endothelial dysfunction and inflammatory signaling.
Anti-inflammatory dietary patterns can address these overlapping risk factors simultaneously.
Diets rich in fiber from vegetables, legumes, and whole grains improve lipid profiles, reduce inflammation, and enhance insulin sensitivity (Williams et al., 2025).
Replacing saturated fats with monounsaturated and polyunsaturated fats helps lower vascular inflammation and improve endothelial function.
Reducing sodium intake to below 2,300 milligrams per day, and ideally closer to 1,500 milligrams per day, further supports blood pressure control (Williams et al., 2025).
Umbrella reviews of dietary patterns confirm that Mediterranean and vegetarian diets consistently improve inflammatory markers such as C-reactive protein, interleukin-6, interleukin-1 beta, and interleukin-10 in adults with chronic cardiometabolic conditions (Reyneke et al., 2025).
Diet, Lifestyle, and Residual Inflammatory Risk
For patients with controlled LDL levels on statins but persistent metabolic risk factors or high CAC, inflammation may represent residual cardiovascular risk.
The ACC emphasizes that regular physical activity, defined as at least 150 minutes per week of moderate aerobic exercise, reduces inflammatory signaling and works synergistically with an anti-inflammatory diet (Mensah et al., 2025).
Smoking cessation is also essential because tobacco use increases pro-inflammatory cytokines and reduces the body’s ability to resolve inflammation (Mensah et al., 2025).
The Bottom Line on Anti-Inflammatory Diet and Heart Disease
Heart disease is not solely a cholesterol problem. It is also an inflammatory and metabolic condition.
An anti-inflammatory diet, particularly a Mediterranean-style dietary pattern, can:
- Reduce inflammatory biomarkers
- Improve insulin sensitivity
- Lower triglycerides
- Decrease blood pressure
For patients with high coronary artery calcium, elevated A1C, hypertension, or hypertriglyceridemia, dietary changes address multiple drivers of cardiovascular risk simultaneously.
Even when LDL and ApoB are well controlled with medication, nutrition remains a foundational strategy for long-term heart protection.
About the Author
Joseph Lehrberg, MS, RD is a registered dietitian specializing in cardiovascular and metabolic health and founder of CardioFunction Integrative Nutrition Services, a nutrition practice based in Boston. He works with patients with elevated cholesterol, high coronary artery calcium scores, high triglycerides, statin intolerance, and other cardiometabolic risk factors to develop evidence-based nutrition strategies for long-term heart health.
Learn more about working with him here.
References
Williams KA, Aggarwal M, Agustina R, et al. Nutrition and Front-of-Package Food Labeling as a Catalyst for Cardiovascular Health: 2025 ACC Concise Clinical Guidance. Journal of the American College of Cardiology. 2025.
Mensah GA, Arnold N, Prabhu SD, Ridker PM, Welty FK. Inflammation and Cardiovascular Disease: 2025 ACC Scientific Statement. Journal of the American College of Cardiology. 2025.
Yu X, Pu H, Voss M. Overview of Anti-Inflammatory Diets and Their Promising Effects on Non-Communicable Diseases. British Journal of Nutrition. 2024.
Hornero-Ramirez H, Aubin A, Michalski MC, et al. Multifunctional Dietary Interventions, Low-Grade Inflammation and Cardiometabolic Profile. Frontiers in Immunology. 2023.
Reyneke GL, Lambert K, Beck EJ. Dietary Patterns Associated With Anti-Inflammatory Effects: An Umbrella Review of Systematic Reviews and Meta-Analyses. Nutrition Reviews. 2025.
Li J, Lee DH, Hu J, et al. Dietary Inflammatory Potential and Risk of Cardiovascular Disease Among Men and Women in the U.S. Journal of the American College of Cardiology. 2020.
Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Journal of the American College of Cardiology. 2023.
