Can lowering cholesterol actually reverse artery plaque, or does it mainly prevent further buildup?

Substantial LDL lowering can produce some regression of coronary plaque, not just slower accumulation. In GLAGOV, people with coronary disease received evolocumab or placebo on top of statin treatment and underwent intravascular ultrasound. The evolocumab group had a modest average reduction in plaque burden, with regression seen more often than in the placebo group. This was a change measured in selected coronary segments, not evidence that the arteries became plaque-free or that years of exposure could be erased quickly.[1]

Plaque regression and prevention of heart attacks are related but distinct outcomes. FOURIER separately demonstrated fewer cardiovascular events with evolocumab in patients with established disease. A person can gain protection without dramatic visible shrinkage of a plaque, and a better lipid panel cannot prove that existing lesions have disappeared. Treatment remains a long-term strategy that also includes the other cardiovascular risk factors. Neither an imaging improvement nor a low ApoB result makes continued high-risk exposures harmless.[1][2]