BACKGROUND: The cardiometabolic index (CMI) serves as a significant marker of diabetes mellitus (DM) and may predict the potential for cardiovascular disease development. Nevertheless, the correlation between CMI and atherosclerotic cardiovascular disease (ASCVD) among individuals exhibiting varying glucose metabolism statuses (GMS) continues to be unclear. METHODS: Overall, 24,006 individuals aged 20 and above were enrolled in the research, drawn from the National Health and Nutrition Examination Survey (NHANES) database. Individuals in the study was classified into three distinct categories according to the level of fasting plasma glucose or glycated haemoglobin: normal glucose regulation, prediabetes, and DM. Multivariate logistic regression models and smoothed curve-fitting techniques were applied to investigate the correlation between CMI and ASCVD risk across varying GMS. Additionally, subgroup analyses stratified by relevant factors were performed to identify potential effect modifiers in this relationship. RESULTS: Overall, 2352 participants (9.8%) with ASCVD were included. An increasing trend in ASCVD risk was observed for each successive CMI tertile. After adjusting for all related covariates, a significantly positive association was observed between CMI and ASCVD (P = 0.0004). Participants with DM in the highest CMI tertile had a 114% higher ASCVD risk compared to those in the lowest tertile (OR = 2.14
95% CI = 1.30-3.53). Smoothed curve-fitting consistently confirmed the correlation between CMI and ASCVD across diverse GMS. Subgroup analyses and interaction tests highlighted statistically significant differences within the drinking status subgroup (P-interaction = 0.0479) and GMS subgroups (P-interaction = 0.0397). CONCLUSION: This research suggests a positive association between ASCVD and CMI in adults in the United States, particularly among individuals with DM.