Most people don’t spend a lot of time thinking about atherosclerosis. After all, you can’t see any buildup of waxy plaque that may exist in your arteries, and the disease doesn’t make itself known until it’s advanced.
“It can progress for decades before you have symptoms like chest discomfort or shortness of breath,” explains Dr. Ron Blankstein, a cardiovascular imaging specialist and preventive cardiologist at Harvard-affiliated Brigham and Women’s Hospital.
Yet atherosclerosis quietly and invisibly puts many millions of people at risk for heart attack, stroke, leg amputation, disability, and even death.
Picture this
Your arteries are like smooth pipes that carry blood throughout your body.
But risk factors for atherosclerosis such as smoking, high blood pressure, inactivity, diabetes, family history, and even infections or inflammation can cause the lining of the artery wall (the endothelium) to become damaged, making it susceptible to deposits of cholesterol.
You may have too much cholesterol floating around in your blood if you eat a diet high in saturated fats (such as those found in processed meats, red meat, and butter).
Those fats stoke the liver to produce higher levels of low-density lipoprotein, or LDL — little packages of cholesterol linked to protein, which travel around the body in the blood.
We need some cholesterol to make vitamin D, hormones, bile that aids digestion, and the coverings of our cells.
But excess LDL may wind up lodging in the artery walls, causing plaques of atherosclerosis to grow. Its counterpart, high-density lipoprotein (HDL), may remove some of the deposited cholesterol and carry it away in the bloodstream.
Plaque buildup
When cholesterol is deposited in the artery walls, white blood cells arrive to trap it. But they’re unsuccessful, and the deposits wind up oozing fat and causing inflammation. The mess of cholesterol and white blood cells is called plaque.
But plaque deposits can bulge into the artery and interfere with blood flow. If the plaque is in one of the coronary arteries, which supply your heart, it may cause chest pain with physical activity, a condition called angina.
If it’s in your brain, it may cause a decline in thinking skills known as vascular dementia. If it’s in your arms or legs, the buildup is known as peripheral artery disease, and it may cause a painful condition called claudication.
Devastating consequences
If the plaque breaks open, a blood clot will form around it and may completely block blood flow to your heart (a heart attack), brain (a stroke), or any part in your body (the kidneys, intestines, legs), killing healthy tissue within minutes.
If blood flow to your foot is completely blocked, for example, the foot can die and require amputation. Atherosclerotic clots are so common that annually they cause
- 370,000 deaths from coronary artery disease (primarily heart attacks)
- almost 800,000 heart attacks
- almost 700,000 strokes.
There is encouraging news: “Many if not most cardiovascular events can be prevented,” says Dr. Blankstein.
Primary prevention
Don’t wait until you have atherosclerosis symptoms — such as unexplained chest pain or pain anywhere there might be a blocked artery, fatigue and shortness of breath with physical activity, and muscle weakness
Control underlying conditions. Obesity, high blood pressure, diabetes, and high cholesterol are all linked to various artery diseases (such as coronary or peripheral artery disease).
Note: Doctors no longer focus on a single cholesterol target for blood levels of HDL, LDL, or total cholesterol. Instead, they take a more personalized approach to controlling cholesterol based on all your risk factors, of which cholesterol levels are just one.
“But in general, the lower your cholesterol the better. We try to keep LDL lower than 100 milligrams per deciliter, or below 70 for those who are at highest risk,” Dr. Blankstein advises.
Exercise.Updated cholesterol management guidelines from the American College of Cardiology and the American Heart Association, published online Nov. 12, 2018, by Circulation, recommend at least 40 minutes of aerobic activity (the kind that gets your heart and lungs pumping) three or four days per week.
Exercising can lower blood pressure, burn body fat, and lower blood sugar levels. Exercise combined with weight loss can also lower LDL levels.
Eat a healthy diet. “The two diets that may help most are a plant-based diet, free of animal products, which has been shown in some observational studies to improve blood flow and reverse coronary artery disease to some extent; and a Mediterranean-style diet, which has been shown to reduce cardiovascular events, mostly stroke, compared with a Western diet,” Dr. Blankstein says.
A plant-based diet maximizes consumption of fruits, vegetables, whole grains, and legumes like beans, peas, and lentils, while minimizing processed foods.
A Mediterranean diet includes generous quantities of olive oil, fruits, vegetables, nuts, whole grains, and fish; limited portions of red meats or processed meats; and moderate amounts of cheese and wine.
Quit smoking.Toxins in tobacco smoke damage the lining of the arteries, and smoking is one of the most common reasons people experience heart attacks at an early age.
Cholesterol-lowering medications
If you are at increased risk for cardiovascular disease or if you have already had a heart attack, stroke, or the diagnosis of angina or peripheral artery disease, your doctor may want to put you on a statin drug to try to fend off cholesterol buildup in the arteries and shrink plaques.
Statins — such as atorvastatin (Lipitor), rosuvastatin (Crestor), lovastatin (Mevacor), and pravastatin (Pravachol) — block the liver enzyme that promotes cholesterol production. Another medication called ezetimibe (Zetia) may be added to block cholesterol absorption in the digestive tract.
Statins have been shown to reduce the risk of heart attack, stroke, and death. However, they have rare side effects, including elevated blood sugar (if you’re on the border of having diabetes, you may be more likely to cross the threshold), temporary muscle aches, a potentially life-threatening breakdown of muscle cells, and liver problems.
On the fence
If a decision about statin therapy is uncertain, the new cholesterol guidelines suggest considering a noninvasive test called a coronary artery calcium (CAC) scan, which measures specks of calcium in the heart’s arteries (a clue to the presence of plaque).
“But you should only consider the test if the results will lead to a change in medical therapy,” Dr. Blankstein says. “It’s for people in a gray area regarding their level of risk, or who have a strong preference for avoiding treatment. If the test shows you have significant plaque, you can be more aggressive in your treatment.
If it shows you don’t have plaque, you may prefer avoiding medication and focusing on lifestyle.”
Can we reverse atherosclerosis?
With proper treatment, it’s possible to halt atherosclerosis and even reverse it to a small extent. “We can’t take someone with severe disease and make their arteries look normal. But at a minimum, we can stop progression and reverse it in some cases with intense treatment,” Dr. Blankstein says.
For people with advanced disease, it will likely take a combination of lifestyle changes (like eating better and exercising more) and medications to stop or reverse atherosclerosis.
“But in those who do not have atherosclerosis,” notes Dr. Blankstein, “we can prevent many of the risk factors that lead to this disease, and dramatically lower the risk of cardiovascular events, with lifestyle alone.”
