It's reversible: shrinking & stabilising plaque

For decades atherosclerosis was assumed to be a one-way street. The imaging trials proved otherwise: push ApoB/LDL low enough for long enough and plaque stops growing, shrinks — and, more importantly, turns from soft and dangerous into stable and quiet.

The regression ladder

Lower LDL, more regression: Serial ultrasound-inside-the-artery (IVUS) trials line up as a dose-response ladder measuring percent atheroma volume (PAV). REVERSAL: LDL 110 progressed (+2.7%), LDL 79 halted. ASTEROID: LDL 61 regressed plaque (−0.98%) — the first clear reversal. SATURN: both maximal statins regressed (~−1%). GLAGOV: adding a PCSK9 inhibitor drove LDL to 37 mg/dL and regressed plaque in 64% of patients, with benefit continuing down to LDL ~20 and no floor. Evidence ●●●●○

Stabilisation matters more than shrinkage

Turning soft into stable: Shrinking volume is only half of it. In the HUYGENS and PACMAN-AMI trials, intensive lowering with a PCSK9 inhibitor roughly doubled fibrous-cap thickening, shrank the lipid core, and cut plaque inflammation — remodelling plaque toward a stable, rupture-resistant form. Evidence ●●●●○
The calcium paradox: Counterintuitively, statins increase dense coronary calcium even as they regress plaque and cut events. This isn't harm — it's the soft, inflamed plaque converting to dense, quiet calcium. So a rising calcium score on a statin is usually stabilisation, not failure — which is why calcium density, not just the total score, now matters.

How low, how long

Slow, sustained, and it holds: Net regression tends to begin once LDL is pushed below ~70 mg/dL, and it keeps improving with no clear lower limit. But plaque changes are slow — every trial ran 18–24+ months to shift PAV ~1% — so this is a matter of years of sustained low ApoB, not a quick fix, and stopping reverses the gains. The imaging changes are surrogates, but they're corroborated by hard-outcome trials (FOURIER) using the same drugs.

The reassuring headline

Atherosclerosis is a modifiable, measurable, and even reversible disease — not a sentence. The lever is ApoB/LDL, kept low for years. How you pull it — lifestyle, drugs, or both — is the rest of this guide.

The Cholesterol Guide