Medically Reviewed by Dr. K. Updated as of May 25, 2022.
Table of contents
Heart Disease, Cholesterol and Atherosclerosis
Heart disease can be caused by cholesterol plaques. Plaques form in the walls of arteries and grow over time. Cholesterol plaques gradually block blood supply in the arteries. A cholesterol plaque may rupture, which is even worse. A heart attack or stroke is caused by a sudden blood clot that forms over the rupture.
Plaque buildup and blood clots block arteries, and is the main cause of death in the United States. Cholesterol and other risk factors should be reduced to better prevent cholesterol plaque formation. It may even be able to reverse some plaque buildup in some cases.
Cholesterol Plaques and Atherosclerosis
Atherosclerosis is the process by which cholesterol plaques develop. It's also known as “arterial hardening." The raw material for cholesterol plaques is LDL, or “bad cholesterol." It has the potential to damage the arteries that transport blood from your heart to the rest of the body. After the damage has begun, LDL continues to accumulate in the artery walls. Atherosclerosis is a silent and gradual process that causes cholesterol plaques to form.
Atherosclerosis plaques are the most common cause of cardiac attacks, strokes, and peripheral arterial disease. Together, these factors play a significant role in the development of cardiovascular disease. Cardiovascular disease is the leading cause of death globally, killing 17.9 million a year, accounting for an estimated of 31% of the world’s deaths each year.
Understanding Cholesterol Plaque
Cholesterol plaques begin to develop in the arteries' walls. Atherosclerosis can be detected in the arteries even before they can be called plaques. Even several teenagers have cholesterol “fatty streaks" in their artery walls. These streaks are the first signs of cholesterol plaque formation. Imaging and tests can be difficult in detecting them. However, they have been discovered during autopsies of young victims of accidents and violence.
Atherosclerosis is a long-term condition that progresses over time. It occurs as a result of a complicated process that consists of the following:
- Damaged endothelium: The endothelium is the smooth, delicate lining of blood vessels. The endothelium may be damaged by high cholesterol, smoking, high blood pressure, or diabetes, allowing cholesterol to enter the artery wall.
- Cholesterol invasion: The damaged endothelium is crossed by “bad"
cholesterol (LDL cholesterol) circulating in the blood. LDL cholesterol begins to accumulate in the artery wall.
- Plaque formation: The LDL cholesterol is digested by white blood cells. Through time, the amalgamation of cholesterol and cells hardens into a cholesterol plaque in the artery's wall.
How Cholesterol Plaque Attacks
Cholesterol plaques may act in a number of ways once they've formed.
- They have the ability to remain inside the artery wall. The cholesterol plaque may eventually stop growing or grow into the wall, out of the blood flow.
- Plaques may grow in the direction of blood flow in a gradual, regulated manner. Except in severely blocked arteries, slow-growing cholesterol plaques may or may not ever trigger any symptoms.
- In the worst-case situation, cholesterol plaques may rupture unexpectedly. Blood would be able to clot within an artery as a result of this. This triggers a heart attack in the heart. It triggers a stroke in the brain.
The three major types of cardiovascular disease are caused by cholesterol plaques from atherosclerosis:
- Coronary artery disease. Stable cholesterol plaques in the arteries of the heart may cause no symptoms or it may cause angina (chest pain). Blocked arteries are caused by sudden cholesterol plaque rupture and clotting. The heart muscle dies as a result of this. Myocardial infarction is the medical term for this heart attack.
- Cerebrovascular disease. Cholesterol plaque in one of the brain's arteries may rupture. This results in a stroke, which results in irreversible brain damage. Transient ischemic attacks, or TIAs, may also be caused by blockages. The symptoms of a TIA are similar to those of a stroke. However, they are just temporary, and there is no long-term damage to the brain. Patients who have a TIA, on the other hand, are at a far higher risk of a stroke later on, so medical attention is critical.
- Peripheral arterial disease (PAD). Because of poor circulation, blocked arteries in the legs may trigger pain while walking and delay wound healing. Amputations may be required if the disease is severe.
Preventing Cholesterol Plaques
Atherosclerosis and cholesterol plaques develop over time, suggesting they worsen over time. They can be prevented. Up to 90% of all heart attacks are caused by these risk factors:
- High cholesterol levels
- High blood pressure
- Insufficient fruits and vegetables in your diet
- Excessive alcohol consumption: women should not have more than one drink a day, and men should not have more than one or two drinks a day.
- Insufficient physical activity on a regular basis.
You'll find that nearly every one of them has one thing in common: you can do something about it. Experts believe that lowering the risk factors lowers your chances of developing heart disease.
Taking a small dose of aspirin a day may be beneficial for patients who are at a higher risk of cholesterol plaques. Aspirin prevents blood clots from developing. Before taking aspirin, see the doctor because it may cause side effects.
Shrinking Cholesterol Plaques
Once a cholesterol plaque has formed, it is usually permanent. However, plaque buildup can be slowed or stopped with treatment.
According to some research, cholesterol plaques may also shrink slightly when treated aggressively. Cholesterol plaques shrank 10% in size following a 50% drop in blood cholesterol levels, according to one major research.
Keeping cholesterol plaques from forming or progressing is the only approach to treat them. This can be accomplished by lifestyle changes and, if necessary, drug prescription.
Drugs and Lifestyle Changes
Atherosclerosis may be slowed or stopped by reducing the risk factors that cause it. Taking cholesterol and blood pressure drugs, maintaining a balanced diet, exercising more, and not smoking are all ways to lower the cholesterol levels. These treatments would not clear blocked arteries. However they can reduce the likelihood of heart attacks and strokes.
Here's some tips to help you improve your cholesterol and lower your chances of developing atherosclerosis:
- Exercise raises “good" HDL cholesterol and lowers the likelihood of heart attacks and strokes, whether or not you lose weight.
- Low-fat, high-fiber diets may help reduce “bad" LDL cholesterol.
- Oily fish and other omega-3 fatty acids rich foods will boost “good” HDL cholesterol levels.
- Speak to the doctor regarding how to lower your cholesterol if you believe or think it is high, or if you have a family history of high cholesterol.
Cholesterol levels may be lowered by the use of some medications.
The most commonly used cholesterol-lowering medications are statins. They will reduce “bad" LDL cholesterol by as much as 60% or more. They will also help to raise HDL levels. Statins have been shown in studies to lower the risk of heart attacks, strokes, and death due to atherosclerosis.
Statins can also help reduce triglyceride levels. Triglycerides are fats that lead to atherosclerosis but are not cholesterol.
Taking a statin for a year or more may also shrink atherosclerosis plaques significantly. Most doctors were stunned to learn that atherosclerosis might be reversed, believing it was impossible.
It is currently not possible to completely reverse it. However, taking a statin will lower the likelihood of atherosclerosis complications. It reduces inflammation, which helps to keep the plaque stable. As a result, statins are sometimes used to combat atherosclerosis.
- Atorvastatin (Lipitor)
- Fluvastatin (Lescol)
- Lovastatin (Altoprev, Mevacor)
- Pitavastatin (Livalo)
- Pravastatin (Pravachol)
- Rosuvastatin (Crestor)
- Simvastatin (Zocor)
Statins should be used as part of a larger, personalised strategy that you and your doctor devise together. The plan can be determined, among other factors, by your level of risk for heart attack and stroke, as well as your own lifestyle decisions.
Fibrates are triglyceride-lowering medications. Fibrates also help to raise HDL levels. Below are two examples of Fribates:
- Gemfibrozil (Lopid)
- Fenofibrate (Antara, Fenoglide, Lipofen, Lofibra, Tricor, Triglide, Trilipix)
Nicotinic acid, also known as niacin, is a vitamin that everybody needs in small amounts. It improves cholesterol levels by lowering triglycerides and LDL when taken in large doses. It also raises HDL levels.
Many individuals are unable to take niacin because of uncomfortable skin flushing. (Be careful of over-the-counter preparations labelled “no-flush," since these lack the active source of niacin.) Niacin may also cause blood sugar levels to rise. This is an issue, especially for diabetics.
Niacin is prescribed even less often than statins or fibrates due to its side effects.
Bile acid sequestrants
Bile acid sequestrants are medicines that bind to bile acids in the intestines. As a result, the amount of bile acid in the body decreases. When you don't have enough bile, cholesterol must be used to produce it. Which decreases cholesterol levels in the blood. They are as follows:
- Cholestyramine (Prevalite, Questran)
- Colestipol (Colestid)
- Colesevelam (WelChol)
Some other cholesterol-lowering medications:
Ezetimibe (Zetia): This medication acts by lowering cholesterol absorption in the intestines. It has the ability to lower LDL cholesterol levels. However, it is not as effective as statins. This medication is normally used in conjunction with a statin to help lower bad cholesterol even further. It does not seem to lower the likelihood of heart attacks or strokes.
Plant sterols: These can be taken as pills or found in foods like margarine. Taking plant sterols on a daily basis can help lower cholesterol by around 10%.
Epanova, Lovaza, Omtryg, and Vascepa: These omega-3-rich pharmaceutical medications can be combined with a low-fat diet to help reduce triglyceride levels.
Alirocumab (Praluent) and evolocumab (Repatha): Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors are a new class of medicines. They're for those that can't get their cholesterol in control with food or statin treatment. Evolocumab has since been shown to greatly reduce the risk of heart attacks and strokes in people who have already developed cardiovascular disease.
Drugs to reduce high blood pressure
The risk of atherosclerosis and its complications is reduced as blood pressure is reduced. High blood pressure is seldom brought down to a normal level by diet and exercise alone. The majority of patients with high blood pressure will need several prescriptions (usually at least two).
There are several different types of high blood pressure medications that function in many ways. The type of medication is less significant than the end result: lower blood pressure. According to 2017 guidelines, normal blood pressure should be less than 120/80. People getting treated with high blood pressure have different blood pressure goals depending on their other health conditions.
Drugs to reduce the risk of blood clots
Antiplatelets: These blood thinners help prevent heart attacks and strokes by making blood less prone to clot. Antiplatelets, on the other hand, do not delay or cure atherosclerosis.
Aspirin: Aspirin is an effective blood thinner. A daily dose of aspirin can decrease the likelihood of first heart attacks and strokes by around 25%.
Clopidogrel (Plavix): Clopidogrel is a blood thinner that works similarly to aspirin. This medication prevents clots from developing within stents inserted into the heart's arteries.
Ticagrelor (Brilinta): Ticagrelor is a blood thinner equivalent to clopidogrel. If patients consume more than 100 milligrammes of aspirin a day, this medication may be less efficient. There are 81 milligrammes of aspirin in a “small aspirin." Doctors should be aware of the possibility of utilising higher doses of aspirin with ticagrelor, according to an FDA “black box" alert.
Prasugrel (Effient): This medication is taken by mouth, normally once a day or as prescribed by the doctor, with or without food. It's possible that the doctor would advise you to take it with a low-dose aspirin.
Warfarin (Coumadin): Warfarin is an effective blood thinner that works as an anticoagulant. It is not often used in the treatment of atherosclerosis. It is usually used for other medical conditions involving blood clots, such as atrial fibrillation and deep vein thrombosis; they are treated with warfarin. It has not been shown to be more effective than aspirin in reducing heart attacks.
The advantages of blood thinners are offset by a higher risk of bleeding. The effects of antiplatelets outweigh the consequences for certain patients at risk of atherosclerosis. Before taking aspirin or some other cardiac medication, consult your doctor.
In certain patients, a daily dosage of colchicine (0.5 to 0.6 mg) has been shown to be effective in preventing atherosclerosis. Because of its anti-inflammatory effects, this drug, which is usually used to manage gout, has seen considerable effectiveness in the treatment of coronary disease.
Atherosclerosis is yet to be proved to be curable. Medication and lifestyle improvements, on the other hand, may help to reduce the likelihood of complications.
Doctors may see and unclog arteries, or provide a way for blood to flow around blocked arteries, using invasive procedures. The below are some of the treatments:
- Angiography, angioplasty, and stenting: Doctors may access diseased arteries by inserting a catheter through an artery in the leg or arm. Cardiac catheterization is the name for this technique. On a live X-ray screen, blocked arteries can be seen. The catheter can be inflated with a tiny balloon to compress cholesterol plaque in blocked arteries. Stents are small tubes that are used to keep clogged arteries open. The stent is normally constructed of metal and is designed to last a lifetime. Some stents include medication to prevent the artery from becoming blocked again.
- Bypass surgery: A healthy blood vessel is harvested from the leg or chest by surgeons. They bypass blocked arteries by using the healthy vessel.
There is a chance of complications in these procedures. They're normally reserved for patients who have severe complications or limitations as a result of atherosclerosis-related cholesterol plaques.
Referenced on 26/4/2021
- WHO Cardiovascular Disease Fact Sheet https://www.who.int/health-topics/cardiovascular-diseases/#tab=tab_1
- American Heart Association: “Atherosclerosis," “Cholesterol," “Common Cardiovascular Diseases," “What is Atherosclerosis?" “LDL and HDL Cholesterol: What's Bad and What's Good?" “Cholesterol-Lowering Drugs," “Phytochemicals and Cardiovascular Disease," “Effects of Normal, Pre-hypertensive, and Hypertensive Blood Pressure Levels on Progression of Coronary Atherosclerosis," “Antiplatelet Agents," “Anticoagulants," “Anticoagulation," “Questions and Answers About Statin Therapy."
- Circulation: “High prevalence of coronary atherosclerosis in asymptomatic teenagers and young adults: evidence from intravascular ultrasound.”
- The New England Journal of Medicine: “Recent Trends in Acute Coronary Heart Disease — Mortality, Morbidity, Medical Care, and Risk Factors,” “Helsinki Heart Study: Primary-Prevention Trial with Gemfibrozil in Middle-Aged Men with Dyslipidemia,” “A Comparison of Warfarin and Aspirin for the Prevention of Recurrent Ischemic Stroke.”
- American College of Cardiology: “Advocacy Statement."
- American Journal of Clinical Nutrition: “Cholesterol-lowering effects of dietary fiber: a meta-analysis.”
- Expert Review of Cardiovascular Therapy: “Biomarkers, Atherosclerosis and Cardiovascular Events.”
- Richard Stein, MD, national spokesperson, American Heart Association; professor of medicine and director of urban community cardiology program, New York University School of Medicine, New York.
- News release, FDA.
- Circulation: “Vasopeptidase inhibitors: a new therapeutic concept in cardiovascular disease?” “Beneficial cardiovascular pleiotropic effects of statins,” “Influence of pravastatin and plasma lipids on clinical events in the West of Scotland Coronary Prevention Study (WOSCOPS).”
- Lancet: “Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial.”
- Nature Clinical Practice: Endocrinology and Metabolism: “Measure for measure — sugar or fats? Reconciling cardiovascular and diabetes risk with niacin therapy.”
- BMJ: “Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.”