Atherosclerosis

    Written by:
    Detrick Snyder, Gregory Lopez

    Fact-checked

    by:

    Mike Murray, James Gaylor
    Last Updated: October 13, 2024

    Atherosclerosis is the buildup of lipid-rich plaque on arteries’ interior lining. While symptomless early on, it can lead to artery blockage and increased clot formation, which can cause a wide range of serious diseases, most commonly coronary heart disease and stroke. Lifestyle factors, such as poor diet, little exercise, and smoking, can be integral in the progression of atherosclerosis and its associated diseases.

    Atherosclerosis falls under the Cardiovascular Health category.

    24 references on this page
    9,161 participants in 7 trials and 5 meta-analyses

    What is atherosclerosis?

    Atherosclerosis refers to the buildup of fatty plaque on the interior lining of the arteries — the medium- and large-sized blood vessels that carry nutrients and oxygen to tissues throughout the body. The formation of these plaques damage the inside surface of the arteries and leads to more plaque buildup, inflammation, artery hardening and narrowing, and an increased risk of clotting.[1] Severe plaque buildup leads to a wide range of diseases, including coronary artery disease, carotid artery disease (blockage of the arteries feeding into the brain), and peripheral arterial disease (blockage of arteries in the arms, legs, or pelvis).[2]

    Atherosclerosis should not be confused with arteriosclerosis, which is a broader term referring to general thickening and stiffening of blood vessels of all sizes; atherosclerosis is a specific kind of arteriosclerosis. [1]

    What are the main signs and symptoms of atherosclerosis?

    Atherosclerosis can be visualized using a process called angiography. While this is one of the better methods for assessing atherosclerosis, it’s not usually used for routine screening since it’s invasive.[3] Other less invasive methods can be used to assess atherosclerosis, including coronary calcium scans that measure calcium buildup inside heart arteries (less invasive, but involves radiation exposure) and the ankle-brachial test (noninvasive; mainly relates to atherosclerosis in the peripheral arteries, but atherosclerosis in the periphery is correlated with atherosclerosis elsewhere in the body[3]), as well as ultrasonography.[4]

    Atherosclerosis is usually symptomless until it starts causing other atherosclerotic cardiovascular diseases like coronary artery disease.[5]

    How is atherosclerosis diagnosed?

    Preclinical atherosclerosis isn’t usually diagnosed directly through imaging or the other measurements mentioned above. However, once it manifests clinically, it may be caught during imaging or through the criteria for the clinical diseases it leads to (e.g., peripheral artery disease). Atherosclerosis may also be presumed on the basis of risk factors such as biomarkers like high blood pressure or LDL-C, demographics like age, or behaviors like smoking.

    What are some of the main medical treatments for atherosclerosis?

    Medical treatment options depend on the type of clinical disease and how far it’s progressed.

    If a person doesn’t have clinical disease yet, then the main medical treatments usually target the major risk factors of high cholesterol and high blood pressure using drugs like statins and antihypertensives as spelled out in major guidelines.[6]

    Medical treatment is often added on top of lifestyle changes, since lifestyle plays a large role in atherosclerosis. The major lifestyle recommendations are discussed more fully below.

    Have any supplements been studied for atherosclerosis?

    Yes, although exactly which supplements qualify depends on whether you count studies involving markers tightly related to atherosclerosis like LDL-C or only count studies that measure atherosclerosis more directly. A lot more studies have looked at biomarkers related to atherosclerosis than direct measurements. However, since a lot of studies have examined biomarkers like LDL-C and blood-pressure that are firmly established to actually cause atherosclerosis, the evidence base isn’t too bad.

    A very incomplete list of supplements examined for impact on atherosclerosis or its biomarkers include:[7]

    • Omega-3 and omega-6 polyunsaturated fatty acids
    • garlic and allicin (one of garlic’s main bioactives)
    • Plant sterols
    • Flavanols
    • Fiber
    • Antioxidant vitamins such as vitamin-c

    How could diet affect atherosclerosis?

    Diet plays a huge role in atherosclerosis through impacting many of its associated risk factors, such as obesity, high cholesterol, high blood-pressure, and diabetes. Recent guidelines cite strong evidence that weight loss in people with overweight or obesity can reduce atherosclerotic disease risk. There’s also strong evidence that a diet high in fruits and vegetables, legumes, nuts, whole grains, and fish can reduce the risk for diseases caused by atherosclerosis. Weaker evidence suggests that swapping out saturated fat with mono- or polyunsaturated fats and minimizing processed meats and refined carbohydrates can also help.[6]

    Can you reverse plaque buildup in the arteries?

    Are there any other treatments for atherosclerosis?

    The biggest lifestyle change that can impact atherosclerosis is quitting smoking[8]. Getting aerobic exercise is also extremely important. To reduce atherosclerotic risk, people should ideally perform at least 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or a combination of the two each week.[6] A rule of thumb to measure intensity is the talk test: moderate aerobic activity makes it hard to sing but not to talk, whereas it’s hard to say more than a few words at a time during vigorous aerobic exercise.

    What causes atherosclerosis?

    Atherosclerosis starts with damage to the interior lining of medium and large arteries, which often occurs in arteries that are under high pressure and tension, a process that can start in childhood.[9] This damage leads to the fats — which are mostly in the form of low density lipoprotein (LDL), but can also be carried by other apolipoprotein B-containing lipoproteins[10] — being trapped in the interior arterial lining. The more such lipoproteins there are, the more that can get trapped. The fats then get oxidized, which attracts white blood cells — mainly macrophages — to try to clean up the mess. However, when there’s a lot of fat to clean up, the macrophages overdo it and transform into foam cells, which is one of the main ingredients of atherosclerotic plaque formation.

    Does cholesterol really cause atherosclerosis?

    Examine Database: Atherosclerosis

    Research FeedRead all studies

    Frequently asked questions

    What is atherosclerosis?

    Atherosclerosis refers to the buildup of fatty plaque on the interior lining of the arteries — the medium- and large-sized blood vessels that carry nutrients and oxygen to tissues throughout the body. The formation of these plaques damage the inside surface of the arteries and leads to more plaque buildup, inflammation, artery hardening and narrowing, and an increased risk of clotting.[1] Severe plaque buildup leads to a wide range of diseases, including coronary artery disease, carotid artery disease (blockage of the arteries feeding into the brain), and peripheral arterial disease (blockage of arteries in the arms, legs, or pelvis).[2]

    Atherosclerosis should not be confused with arteriosclerosis, which is a broader term referring to general thickening and stiffening of blood vessels of all sizes; atherosclerosis is a specific kind of arteriosclerosis. [1]

    What are the main signs and symptoms of atherosclerosis?

    Atherosclerosis can be visualized using a process called angiography. While this is one of the better methods for assessing atherosclerosis, it’s not usually used for routine screening since it’s invasive.[3] Other less invasive methods can be used to assess atherosclerosis, including coronary calcium scans that measure calcium buildup inside heart arteries (less invasive, but involves radiation exposure) and the ankle-brachial test (noninvasive; mainly relates to atherosclerosis in the peripheral arteries, but atherosclerosis in the periphery is correlated with atherosclerosis elsewhere in the body[3]), as well as ultrasonography.[4]

    Atherosclerosis is usually symptomless until it starts causing other atherosclerotic cardiovascular diseases like coronary artery disease.[5]

    How is atherosclerosis diagnosed?

    Preclinical atherosclerosis isn’t usually diagnosed directly through imaging or the other measurements mentioned above. However, once it manifests clinically, it may be caught during imaging or through the criteria for the clinical diseases it leads to (e.g., peripheral artery disease). Atherosclerosis may also be presumed on the basis of risk factors such as biomarkers like high blood pressure or LDL-C, demographics like age, or behaviors like smoking.

    What are some of the main medical treatments for atherosclerosis?

    Medical treatment options depend on the type of clinical disease and how far it’s progressed.

    If a person doesn’t have clinical disease yet, then the main medical treatments usually target the major risk factors of high cholesterol and high blood pressure using drugs like statins and antihypertensives as spelled out in major guidelines.[6]

    Medical treatment is often added on top of lifestyle changes, since lifestyle plays a large role in atherosclerosis. The major lifestyle recommendations are discussed more fully below.

    Have any supplements been studied for atherosclerosis?

    Yes, although exactly which supplements qualify depends on whether you count studies involving markers tightly related to atherosclerosis like LDL-C or only count studies that measure atherosclerosis more directly. A lot more studies have looked at biomarkers related to atherosclerosis than direct measurements. However, since a lot of studies have examined biomarkers like LDL-C and blood-pressure that are firmly established to actually cause atherosclerosis, the evidence base isn’t too bad.

    A very incomplete list of supplements examined for impact on atherosclerosis or its biomarkers include:[7]

    • Omega-3 and omega-6 polyunsaturated fatty acids
    • garlic and allicin (one of garlic’s main bioactives)
    • Plant sterols
    • Flavanols
    • Fiber
    • Antioxidant vitamins such as vitamin-c
    How could diet affect atherosclerosis?

    Diet plays a huge role in atherosclerosis through impacting many of its associated risk factors, such as obesity, high cholesterol, high blood-pressure, and diabetes. Recent guidelines cite strong evidence that weight loss in people with overweight or obesity can reduce atherosclerotic disease risk. There’s also strong evidence that a diet high in fruits and vegetables, legumes, nuts, whole grains, and fish can reduce the risk for diseases caused by atherosclerosis. Weaker evidence suggests that swapping out saturated fat with mono- or polyunsaturated fats and minimizing processed meats and refined carbohydrates can also help.[6]

    Can you reverse plaque buildup in the arteries?

    Atherosclerosis has long been considered to be a progressive, irreversible condition; once it starts, there is no way to reverse — or so we thought. Evidence from animal and human studies using drugs has made it clear that atherosclerosis can actually be reversed to some degree.[19] There’s also some evidence from studies that image blood vessels have shown that atherosclerosis can be reversed by diet and lifestyle interventions to some extent as well, although the evidence is more confounded since most of the evidence looks at combined, complex lifestyle interventions.[20] For example, a holistic lifestyle and plant-based diet intervention showed reversal of blocked arteries.[21] Also, an olive oil-rich Mediterranean diet was able to reduce the thickness of artery plaque among people with coronary artery disease.[22]

    Weight loss is well-established to prevent atherosclerosis,[6] but weight loss has lackluster effects on reversing established atherosclerosis in people with type 2 diabetes.[23] Overall, it looks like adopting a healthy dietary pattern may either slow or possibly reverse the narrowing of arteries due to atherosclerosis, particularly in early stages of plaque formation[24], and these effects are enhanced alongside lifestyle changes like exercising, stress management, and quitting smoking.

    Are there any other treatments for atherosclerosis?

    The biggest lifestyle change that can impact atherosclerosis is quitting smoking[8]. Getting aerobic exercise is also extremely important. To reduce atherosclerotic risk, people should ideally perform at least 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or a combination of the two each week.[6] A rule of thumb to measure intensity is the talk test: moderate aerobic activity makes it hard to sing but not to talk, whereas it’s hard to say more than a few words at a time during vigorous aerobic exercise.

    What causes atherosclerosis?

    Atherosclerosis starts with damage to the interior lining of medium and large arteries, which often occurs in arteries that are under high pressure and tension, a process that can start in childhood.[9] This damage leads to the fats — which are mostly in the form of low density lipoprotein (LDL), but can also be carried by other apolipoprotein B-containing lipoproteins[10] — being trapped in the interior arterial lining. The more such lipoproteins there are, the more that can get trapped. The fats then get oxidized, which attracts white blood cells — mainly macrophages — to try to clean up the mess. However, when there’s a lot of fat to clean up, the macrophages overdo it and transform into foam cells, which is one of the main ingredients of atherosclerotic plaque formation.

    Does cholesterol really cause atherosclerosis?

    Put simply: pretty much, yes. If you go to the doctor, and get your “bad cholesterol” (LDL-C) measured, that will predict heart disease risk very well. But the details are a bit more complicated, so let’s go over them.

    Low density lipoproteins (LDL) are one of several types of particles that transport fats in the blood. Fats need to be packaged like this since they’re hydrophobic (i.e., they’ll separate out in water), and the blood is mostly water.

    The liver releases fats to the bloodstream by packaging them in very-low density lipoproteins (VLDLs) that contain both triglycerides and cholesterol. These VLDLs provide the body with fats, and in the process of delivering those fats, are transformed into LDL.[11]

    LDL particles are very widely accepted as being a main cause of atherosclerosis.[12][13] But clinics don’t usually measure LDL particles. Insead, they usually measure the amount of cholesterol contained in LDL particles: LDL-C. Because LDL is very cholesterol-rich, this serves as an excellent proxy for LDL levels in the blood, and thus correlates very well to atherosclerotic risk.

    But the blood level of LDL-C alone does not tell the whole story of atherosclerosis.[14]

    First, any cholesterol particle with a specific protein called ApoB, including LP(a), remnant particles, and very low density, low density, and intermediate density lipoproteins, can play a role in depositing fats like cholesterol and triglycerides into vessel walls, inducing inflammation, and making atherosclerosis worse.[15] That’s because oxidized particles with ApoB are recognized and taken up by immune cells, which starts building up the fatty streak mentioned above.[16]

    Second, preliminary evidence suggests that LDL particles with different densities have differing atherosclerotic potential: small dense LDL particle levels better predict heart disease risk and may be able to cause more damage than large buoyant LDL particles.[17][15]

    Next, the inflammatory environment in which LDL-C particles are circulating affects the extent and type of immune activation and fatty acid oxidation, which is necessary for atherosclerotic progression.[18]

    Lastly, other components deposited in plaques — oxidized fats, triglycerides, calcium, dead cells, and scar tissue — affect plaque stability and resistance to further damage.[18]

    Taken together, LDL particles which are rich in cholesterol play a major role in causing atherosclerosis, but the presence of other factors may determine the extent of that damage.

    Examine Database References

    1. Serum Platelets - Joanna J Samulak, Angelika K Sawicka, Emilia Samborowska, Robert A OlekPlasma Trimethylamine-N-oxide following Cessation of L-carnitine Supplementation in Healthy Aged WomenNutrients.(2019 Jun 13)
    2. High-density lipoprotein (HDL) - Castaño G, Más R, Fernández JC, Illnait J, Fernández L, Alvarez EEffects of policosanol in older patients with type II hypercholesterolemia and high coronary riskJ Gerontol A Biol Sci Med Sci.(2001 Mar)
    3. High-density lipoprotein (HDL) - Gutierrez AD, Duran-Valdez E, Robinson I, de Serna DG, Schade DSDoes short-term vitamin C reduce cardiovascular risk in type 2 diabetes?Endocr Pract.(2013 Sep-Oct)
    4. High-density lipoprotein (HDL) - AIM-HIGH Investigators, Boden WE, Probstfield JL, Anderson T, Chaitman BR, Desvignes-Nickens P, Koprowicz K, McBride R, Teo K, Weintraub WNiacin in patients with low HDL cholesterol levels receiving intensive statin therapyN Engl J Med.(2011 Dec 15)
    5. High-density lipoprotein (HDL) - Yang L, Zhu W, Zhang X, Zhou X, Wu W, Shen TEfficacy and safety of berberine for several cardiovascular diseases: A systematic review and meta-analysis of randomized controlled trials.Phytomedicine.(2023-Apr)
    6. High-density lipoprotein (HDL) - Bersch-Ferreira ÂC, Stein E, Waclawovsky G, da Silva LR, Machado RHV, Weschenfelder C, Figueiro MF, Suzumura EA, Santos RHN, Duarte GBS, Rogero MM, de Abreu-Silva EO, Cavalcanti AB, Marcadenti AEffect of nuts on lipid profile and inflammatory biomarkers in atherosclerotic cardiovascular disease: a systematic review and meta-analysis of randomized controlled trials.Eur J Nutr.(2024 Jul 5)
    7. Atherosclerotic Signs - Koscielny J, Klüssendorf D, Latza R, Schmitt R, Radtke H, Siegel G, Kiesewetter HThe antiatherosclerotic effect of Allium sativumAtherosclerosis.(1999 May)
    8. Atherosclerotic Signs - Wang S, Chen Y, Wang R, Ma B, Wang Z, Tang G, Wang S, He Y, Qu LEffectiveness of red yeast rice on carotid atherosclerosis: A systematic review and meta-analysis.Front Pharmacol.(2022)
    9. Atherosclerotic Signs - Qin X, Xu M, Zhang Y, Li J, Xu X, Wang X, Xu X, Huo YEffect of folic acid supplementation on the progression of carotid intima-media thickness: a meta-analysis of randomized controlled trials.Atherosclerosis.(2012-Jun)
    10. C-Reactive Protein (CRP) - Koushki M, Dashatan NA, Meshkani REffect of Resveratrol Supplementation on Inflammatory Markers: A Systematic Review and Meta-analysis of Randomized Controlled Trials.Clin Ther.(2018-Jul)
    11. Microcirculation - Suter A, Niemer W, Klopp RA new ginkgo fresh plant extract increases microcirculation and radical scavenging activity in elderly patientsAdv Ther.(2011 Dec)
    12. Pulse Wave Velocity - Katayoshi T, Uehata S, Nakashima N, Nakajo T, Kitajima N, Kageyama M, Tsuji-Naito KNicotinamide adenine dinucleotide metabolism and arterial stiffness after long-term nicotinamide mononucleotide supplementation: a randomized, double-blind, placebo-controlled trial.Sci Rep.(2023-Feb-16)