Atherosclerosis can be treated, and in some cases partially reversed, through a combination of lifestyle changes, cholesterol-lowering medications, blood pressure control, and procedures to restore blood flow in severely blocked arteries. The specific approach depends on how advanced the disease is and your overall cardiovascular risk level. Most people with atherosclerosis will use several of these strategies together.
Lowering LDL Cholesterol Is the Core Strategy
Reducing LDL cholesterol (often called “bad” cholesterol) does more than slow plaque buildup. It can actually shrink existing plaques and make them more stable, meaning they’re less likely to rupture and cause a heart attack or stroke. A meta-analysis of imaging studies found that aggressive cholesterol-lowering therapy reduced plaque volume and thickened the fibrous cap covering plaques by an average of 26 micrometers. That cap thickness is the single most important factor in whether a plaque stays put or breaks open.
Current guidelines set LDL targets based on risk level. If you’ve already had a heart attack, stroke, or have diabetes with organ damage (very high risk), the target is below 55 mg/dL, plus at least a 50% reduction from your starting level. For high-risk patients, the target is below 70 mg/dL with the same 50% reduction requirement. Moderate-risk patients aim for below 100 mg/dL.
Statins remain the first-line medication for reaching these targets. High-intensity statin therapy is the primary driver of measurable plaque shrinkage in imaging studies. When statins alone aren’t enough, adding ezetimibe (a cholesterol absorption blocker) or a PCSK9 inhibitor can push LDL levels further down. PCSK9 inhibitors are injectable medications that help the liver clear more LDL from the bloodstream. A newer option in this class, given as just two injections per year, reduces LDL by about 43% in real-world use and up to 52% in clinical trials.
For people who experience muscle pain or other side effects from statins, bempedoic acid is an alternative that works through a similar pathway but is activated only in the liver, largely avoiding muscle-related problems. In a large trial published in the New England Journal of Medicine, bempedoic acid lowered LDL by about 21 percentage points more than placebo and reduced the risk of major cardiovascular events (heart attack, stroke, cardiovascular death, or the need for a procedure to open blocked arteries) by 13%.
Blood Pressure Targets for People With Atherosclerosis
High blood pressure accelerates plaque growth by damaging artery walls, so controlling it is essential. The targets are tighter than many people expect. European guidelines recommend keeping systolic pressure (the top number) between 120 and 129 mmHg and diastolic pressure (the bottom number) between 70 and 79 mmHg for people with established coronary artery disease. American guidelines set the threshold at below 130/80 mmHg.
Registry data from over 10,000 patients who had procedures to open blocked arteries found that the lowest rates of future heart attacks, strokes, and cardiovascular death occurred at a systolic pressure of 110 to 119 mmHg and a diastolic pressure of 70 to 79 mmHg. Pushing blood pressure too low can also be harmful, so the goal is a relatively narrow window rather than “as low as possible.”
Exercise and Diet Changes That Make a Measurable Difference
Physical activity directly reduces cardiovascular death risk. The baseline recommendation is at least 150 minutes per week of moderate-intensity exercise (brisk walking, cycling, swimming) or 75 minutes of vigorous exercise (running, high-intensity interval training). Meeting that minimum lowers your risk of dying from cardiovascular disease by 22% to 25%.
Doing two to four times the minimum, roughly 300 to 600 minutes of moderate activity per week, brings an additional benefit: a 28% to 38% lower risk of cardiovascular death. Beyond 600 weekly minutes of moderate exercise or 300 minutes of vigorous exercise, there’s no further reduction in death risk, so there’s a clear ceiling to the benefit.
On the dietary side, a Mediterranean-style eating pattern (heavy on vegetables, whole grains, fish, olive oil, and nuts, light on red meat and processed foods) and the DASH diet (which emphasizes fruits, vegetables, low-fat dairy, and limited sodium) are the most studied approaches for cardiovascular protection. Both work primarily by improving cholesterol profiles, reducing blood pressure, and lowering inflammation. Smoking cessation is equally critical. Tobacco use accelerates every stage of atherosclerosis, and quitting produces measurable improvements in artery function within weeks.
Targeting Inflammation Directly
Atherosclerosis is fundamentally an inflammatory disease. Even after cholesterol and blood pressure are well controlled, residual inflammation in artery walls continues to drive cardiovascular events in some people. Low-dose colchicine, a long-established anti-inflammatory medication, has emerged as a treatment specifically for this problem.
In a landmark trial of over 5,500 patients with stable coronary artery disease, adding a daily low-dose colchicine tablet to standard treatment reduced major cardiovascular events by 31% over about two and a half years. The event rate dropped from 9.6% in the placebo group to 6.8% in the colchicine group. In patients recovering from a recent heart attack, the reduction was 23%. This makes colchicine one of the few treatments that addresses a different mechanism than cholesterol-lowering or blood pressure control.
Calcium Scores and Treatment Decisions
If you’re at intermediate cardiovascular risk and unsure whether you need medication, a coronary artery calcium (CAC) scan can help clarify the picture. This quick CT scan measures calcified plaque in your heart’s arteries and produces a score measured in Agatston units.
- Score of 0: Your risk is very low. Statin therapy can typically be deferred, with a repeat scan in 3 to 5 years.
- Score of 1 to 99: Statin therapy is favored, especially if you’re over 55.
- Score of 100 to 299: A moderate-to-high-intensity statin is recommended, along with low-dose aspirin if your bleeding risk is low.
- Score above 300: High-intensity statin therapy and low-dose aspirin are recommended. This score indicates significant plaque burden.
Antiplatelet Therapy After a Heart Attack or Stent
After a stent is placed or following a heart attack, you’ll typically take two antiplatelet medications together (aspirin plus a second blood-thinner that blocks clot formation on the stent surface). The standard duration is at least 6 months after an elective stent placement and at least 12 months after a heart attack. Whether to continue dual therapy beyond a year depends on a careful balance between your risk of future clots and your risk of bleeding complications. People with a history of heart attack may benefit from extended therapy at a reduced dose, but this is an individualized decision.
When Procedures Are Needed
For arteries that are severely narrowed and causing symptoms like chest pain or reduced blood flow to the heart, two main procedural options exist. Angioplasty with stenting threads a small balloon into the blocked artery, inflates it to widen the passage, and leaves behind a mesh tube (stent) to hold it open. Bypass surgery reroutes blood around the blockage using a vessel taken from another part of your body.
A systematic review comparing the two approaches found that, across a large population with single or multiple blocked coronary arteries, stenting produces similar outcomes to bypass surgery in terms of death, heart attack, and stroke rates. The tradeoff is that stented arteries are more likely to narrow again over time, potentially requiring a repeat procedure. Bypass surgery is generally preferred when blockages are extensive and complex, involving multiple vessels or the main artery supplying the left side of the heart.
Neither procedure cures atherosclerosis. The underlying disease process continues in untreated arteries, which is why medication and lifestyle changes remain necessary even after a successful procedure. The combination of aggressive risk factor control with targeted intervention when needed gives the best long-term outcomes.