Is Coronary Plaque Regression Possible?

Stephen L. Kopecky, MD; Francisco Lopez-Jimenez, MD, MBA


January 27, 2021

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This transcript has been edited for clarity.

Francisco Lopez-Jimenez, MD, MBA: Hello, and welcome back to the Mayo Clinic–Medscape video series. I am Francisco Lopez-Jimenez, cardiologist and professor of medicine at Mayo Clinic. Today we will be discussing prevention vs regression of heart disease. I am joined by my colleague, Dr Steve Kopecky, consultant, professor of medicine, and expert in this area. Welcome, Dr Kopecky.

Stephen L. Kopecky, MD: Thank you, Dr Lopez-Jimenez. It is my pleasure to be here.

Is Coronary Artery Disease Regression Possible?

Lopez-Jimenez: I have a very intriguing and important question for you: Is coronary artery disease regression possible?

Kopecky: Yes, very good question. Coronary disease regression is possible. It's been shown in studies, but it's not easy to do. Patients ask us frequently, "Can I make my arteries open up again?" And I tell them, "Yes, but do you ask your dermatologist if you can make your skin look like it was when you were 18 years old, or ask your hairdresser whether you can make your hair young again?" We have to be reasonable and understand that while we can regress some lesions, we cannot change all of them.

Lopez-Jimenez: Do you think that all types of plaques can regress?

Kopecky: Certainly a couple of types of plaques can. One is the lipid-rich plaques, which are more malleable and removable. The other is the calcified plaques. The TACT study, which we were a part of at Mayo, was a chelation study and showed that we really cannot get rid of [calcified plaque] once it is there. That is where the term "hardening of the arteries" comes from. But the lipid-rich plaque can be changed. We have seen this on some CT scan studies where we do serial CT scans for coronary calcium, lower the cholesterol, and because the calcium score is a density score, as you take the cholesterol out, the calcium stays and the calcium density goes up. So there are different plaques, and not all are malleable.

The Lower the Better for LDL-C

Lopez-Jimenez: What do coronary ultrasound studies teach us about cholesterol levels and plaque regression?

Kopecky: That is a great, insightful area. Some of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studies included substudies of ultrasound of the coronary arteries. They showed that as we lowered low-density lipoprotein cholesterol (LDL-C), we got more regression. At about an LDL of 80 mg/dL, with everything else being equal, about half of the subjects had coronary artery disease regression. But as you got the LDL below 60 mg/dL, 90% of the regressable plaques or the lipid-rich plaques could show a regression. It's a great insight. It may be that some of our LDL-C goals are a little higher than we want; it may be more like what we are seeing from Europe, where they are suggesting lower LDL-C goals than we are in this country.

Lopez-Jimenez: Do you think a single medicine can cause coronary plaque regression?

Kopecky: On advertisements we hear "take this medicine" (almost like "eat this food") and it will make things better. I am not sure that there is a single medicine, but if there is one, it will be some of the LDL-C–reducing compounds, such as the PCSK9 inhibitors and other ones that may be coming along, and certainly statins. Every drug study that has been done has used the statins. Clearly, that is a very important medicine but it is not everything; you cannot take one pill and not worry about the rest of your lifestyle.

Don't Forget Stress Reduction

Lopez-Jimenez: We have been focusing a lot of our attention in cardiology toward cholesterol treatment, which is a major factor and certainly a major one to achieve plaque regression. What about other factors? What have we learned from clinical trials about the essential factors necessary to achieve coronary artery disease regression in a patient?

Kopecky: There have not been that many well-done studies, but the ones that have been done have focused on three areas. To get regression, one area is to remove causative agents. Remove the smoking, remove the high blood pressure, remove the high cholesterol. We have to do that because if we don't, you can still have progression even if everything else looks good.

The second thing is to work on the cholesterol. Almost all studies have included statins, depending on when they were done. Statins are important, and the new PCSK9 inhibitors are important ones to try to get the LDL under 60 mg/dL.

The third area is one that none of us really appreciate. Almost every study that has looked at coronary artery disease regression and achieved it has addressed some other factors we do not normally think of, like stress. They addressed stress by including things like meditation. The Lifestyle Heart Trial that was done over 20 years ago by Dean Ornish was heavily funded and had heavy use of yoga to help reduce stress. We have to pay attention to stress because it plays a huge role in damaging our endothelium, which leads to progression of coronary artery disease.

Reducing Inflammation Is Key

Lopez-Jimenez: It seems like coronary plaques cannot disappear. Some obstructions will continue, but the nature of the plaque changes, which is important for the patient. Perhaps this is one of the main messages. The second is that it is not just about the cholesterol, even though for the plaque to regress, the cholesterol has to be low, and perhaps lower than what we have been telling patients for years. And other risk factors, like exercising, stress, and diet, should be controlled. Any other key points that you would like to make?

Kopecky: One way to explain this to ourselves and to our patients is inflammation. Anything that inflames the lining of our arteries can cause problems. A recent study in Journal of the American College of Cardiology looked at the inflammation associated with diet. Red meats, processed meats, ultra-processed foods, sugar-sweetened beverages, refined carbs, and processed carbs all increased inflammation by some of the inflammatory parameters. The foods that decreased it were fruits and vegetables, legumes, and whole grains. We know that these can help reduce our inflammatory pathways in our arteries. And again, that is one reason that stress, lack of sleep, and lack of exercise, which we all know are proinflammatory, also play a role.

Lopez-Jimenez: That is very important because that helps us to understand that plaques are not a fixed problem; they are dynamic and involve inflammation, density, and amount of cholesterol. I think we have been trying to be very simplistic, and that does not necessarily help.

Thank you, Dr Kopecky, for those very important insights. Thank you, the audience, for joining us on | Medscape Cardiology .

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