Coronary Atherosclerosis

How plaque builds up

Atherosclerosis starts as early as childhood and progresses over decades:

1. Damage to the artery lining: high blood pressure, smoking, high blood sugar and turbulence injure the inner lining (endothelium).
2. Cholesterol enters the wall: LDL ("bad") cholesterol particles slip under the lining and become oxidized.
3. Inflammation: white blood cells move in and swallow cholesterol, becoming "foam cells" that form fatty streaks.
4. Plaque growth: smooth muscle cells and scar tissue form a fibrous cap over a fatty core. Calcium is deposited over time.
5. Narrowing or rupture: plaque may slowly narrow the artery (causing stable angina) or its cap may crack. A clot forms on the cracked plaque and can block the artery suddenly, causing a heart attack.

Many heart attacks come from plaques that were not severely narrowing the artery beforehand, which is why prevention focuses on stabilizing all plaque, not just opening tight blockages.

Risk factors

Modifiable

• high LDL cholesterol and lipoprotein(a)
• high blood pressure
• smoking and vaping nicotine
• diabetes and insulin resistance
• obesity, especially around the waist
• physical inactivity
• unhealthy diet high in saturated fat, salt and processed foods
• chronic kidney disease
• chronic inflammatory diseases such as rheumatoid arthritis, lupus, psoriasis and HIV

Non-modifiable

• age (men over 45, women over 55)
• male sex, though risk in women rises after menopause
• family history of early heart disease (father or brother before 55, mother or sister before 65)
• inherited cholesterol disorders such as familial hypercholesterolemia
• South Asian ancestry
• pregnancy complications such as preeclampsia

Symptoms

Coronary atherosclerosis causes no symptoms until it limits blood flow. Then it can cause:

• angina: chest pressure or tightness with exertion or stress, easing with rest
• breathlessness or unusual tiredness with activity, particularly in women, older adults and people with diabetes
• a heart attack: severe or prolonged chest pain, often with sweating, nausea and breathlessness
• heart failure or arrhythmias after heart muscle damage
• sudden cardiac death, sometimes as the first sign

Diagnosis

Risk assessment

Doctors estimate your 10-year risk of heart attack and stroke using age, sex, blood pressure, cholesterol, diabetes and smoking status, with risk calculators such as the AHA PREVENT equations.

Coronary artery calcium (CAC) score

A quick, low-dose CT scan without contrast that measures calcified plaque.

It is most useful for people at intermediate risk who are unsure whether to start a statin.

Tests for people with symptoms

• CT coronary angiography: shows narrowings and non-calcified plaque using contrast dye.
• Stress tests: exercise ECG, stress echocardiogram, nuclear or MRI perfusion scans.
• Invasive coronary angiography: dye injected through a catheter; allows stenting in the same procedure.
• Blood tests: cholesterol panel, lipoprotein(a), HbA1c, kidney function.

Treatment

Lifestyle

• stop smoking completely
• 150 minutes a week of moderate activity
• a Mediterranean-style or DASH diet rich in vegetables, fruit, whole grains, legumes, nuts, fish and olive oil
• lose excess weight
• limit alcohol
• sleep 7 to 9 hours; treat sleep apnea

Medicines

• Statins: lower LDL cholesterol, stabilize plaque and reduce heart attacks and strokes. High-intensity statins can produce modest plaque regression.
• Ezetimibe, PCSK9 inhibitors, inclisiran and bempedoic acid: further lower LDL when needed.
• Antiplatelet medicines: low-dose aspirin for people with established disease, as prescribed. Aspirin is no longer routinely recommended for primary prevention in most older adults.
• Blood pressure medicines.
• Diabetes medicines with heart benefits, such as SGLT2 inhibitors and GLP-1 receptor agonists.
• Anti-anginal medicines for symptoms.

Procedures

• Percutaneous coronary intervention (stenting): for heart attacks and for angina not controlled by medicines.
• Coronary artery bypass surgery: for extensive disease, especially with diabetes or reduced heart function.

Can coronary atherosclerosis be reversed?

Partly. Intensive LDL lowering (to very low levels) has been shown in imaging studies to shrink the fatty part of plaques and make them more stable, even if calcium remains. Stopping smoking and controlling blood pressure and diabetes slow progression. Calcium scores often rise slightly on statins, because plaque becomes calcified and more stable, so a rising score does not necessarily mean treatment is failing.

Frequently asked questions

What does coronary atherosclerosis mean?

It means fatty plaque has built up in the walls of the coronary arteries, which supply blood to the heart. It is the underlying process of coronary artery disease and can lead to angina and heart attacks.

Is coronary atherosclerosis the same as coronary artery disease?

They are closely related. Coronary atherosclerosis is the plaque-building process in the artery walls. Coronary artery disease is the clinical condition it causes, including narrowing, angina and heart attacks. The terms are often used interchangeably.

Can coronary atherosclerosis be reversed?

It can be partly reversed. Intensive cholesterol lowering with statins and other medicines can shrink and stabilize plaque, and lifestyle changes slow its progression. Calcified plaque does not disappear, but the risk of heart attack falls substantially.

What is a good coronary calcium score?

A score of zero is best and means no calcified plaque was detected, indicating low short-term risk. Scores from 1 to 99 suggest mild plaque, 100 to 399 moderate, and 400 or above extensive plaque with high risk.

What are the first signs of coronary atherosclerosis?

Usually there are no early signs. The first symptoms are often chest pressure or breathlessness with exertion (angina). Sometimes a heart attack is the first sign, which is why risk assessment and treating risk factors early matter.