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FRANCISCO LOPEZ-JIMENEZ: Hello. And welcome back to the Mayo Clinic Medscape video series. I am Francisco Lopez-Jimenez, cardiologist and professor of medicine at Mayo Clinic. Today, we will be discussing prevention versus reversion heart disease. I'm joined by my colleague, Dr. Stephen Kopecky, consultant and professor of medicine and expert in this area. Welcome Dr. Kopecky.

STEPHEN L. KOPECKY: Thank you, Dr. Lopez-Jimenez. Pleasure to be here.

FRANCISCO LOPEZ-JIMENEZ: I have a very intriguing and important question for you. Is coronary artery disease regression possible?

STEPHEN L. KOPECKY: Yes. Very good question. Coronary disease regression is possible. It's been shown in studies, but it's not easy to do. And patients ask us this frequently. Can I make my arteries open up again? And I tell them the answer yes, but I also ask them, do you go to your dermatologist and say, can you make your skin look like it was when you're 18 years old again, or your hairdresser and make your hair young again? So we have to be reasonable in understanding that while we can regress some lesions, we can't change all of them.

FRANCISCO LOPEZ-JIMENEZ: Good. Now, do you think that all types of plaques can regress?

STEPHEN L. KOPECKY: Well, certainly there are a couple of types of plaques. One are the lipid rich plaques that are more malleable and removable. The other are the calcified plaques. And the calcified plaques even in the study, like TACT, which we were part of at Mayo, which was a chelation study, show we really can't get rid of it once it's there. I mean, the term "hardening of the arteries" comes from this, we all know.

But the lipid-rich plaque can be changed. And we've seen this on some CT scan studies where we do serial CT scans for coronary calcium, lower the cholesterol. And since the calcium score is a density score, as you take the cholesterol out, the calcium stays. The calcium density goes up. So there are different plaques, and not all or are malleable.

FRANCISCO LOPEZ-JIMENEZ: Another question is, what do coronary ultrasound studies teach us about cholesterol levels and plaque regression?

STEPHEN L. KOPECKY: Yeah. Yeah. That's a great, insightful area in that some of the PCSK9 inhibitor studies actually include sub-studies of ultrasound of the coronary arteries and showed that in relation to low density lipoprotein or LDL cholesterol, that as we lowered it, you got more regression. And at about an LDL of 80, everything else being equal, about half of the subjects had coronary artery disease regression.

But as you got the LDL lower, down below 60, 90% of the regressible plaques, or the lipid rich plaques, could show regression. So it's a great insight, and that may be that some of our LDL goals may be a little higher than we want. And so it may be more like what we're seeing from Europe where they're suggesting lower LDL goals than we are in this country.

FRANCISCO LOPEZ-JIMENEZ: Good. Do you think there is a single medicine that will cause coronary plaque regression?

STEPHEN L. KOPECKY: Yeah. Well, that we certainly see it advertised a lot that take this medicine and almost like eat this food, and it will make things better. I'm not sure that a single medicine but if there is one, it's going to be some of the LDL reducing compounds-- the PCSK9s, the other ones that may be coming along, certainly statins. Every study that's been done has used the statins pretty much if they use a medicine. So clearly, that's a very important medicine, but it's not everything, that you just can't take one pill and not worry about the rest of your lifestyle.

FRANCISCO LOPEZ-JIMENEZ: Yeah. It seems like we have been focusing a lot of our attention in cardiology towards cholesterol treatment, which is a major factor and certainly a major one to achieve plaque regression. But what about other factors? So what have we learned from clinical trials about the essential factors necessary to achieve coronary artery disease regression in a patient?

STEPHEN L. KOPECKY: Yeah. A very good point. And there haven't been that many really well done studies. But the ones that have been done have focused on three areas. One is to get regression, remove causative agents. By that I mean remove the smoking, remove the blood pressure, remove the high cholesterol. We have to do that, because if we don't, you can still have regression even if everything else looks good.

The second thing is to work on the cholesterol. Clearly, almost all studies have included statins depending on when they were done. Statins are important. The new PCSK9 inhibitors, that's an important [INAUDIBLE] of this to try to get the deal certainly well under 60.

And the third area, and this is the thing that none of us really appreciate, is that almost every study that has looked at coronary artery disease regression and achieved it has addressed some other factors we don't normally think of, like stress. They've addressed stress in terms of putting in meditation or looking at the Lifestyle Heart Trial done over 20 years ago by Dean Ornish, heavily funded and heavy use of yoga to help reduce stress. So we have to pay attention to stress, because it plays a huge role in damaging our endothelium, which leads to progression of coronary disease.

FRANCISCO LOPEZ-JIMENEZ: It seems like coronary plaques cannot disappear, that some obstructions will continue, but the nature of the plaque changes. And that is actually very important for the patient. So that's perhaps one of the main messages. And the second is that it is not just about the cholesterol, even though for the plaque to regress, the cholesterol has to be low and perhaps lower than what we have been telling patients for years, and to control the rest of the risk factors, exercising, lowering the stress, healthy diet, et cetera. And any other key points, Stephen, that you would like to make?

STEPHEN L. KOPECKY: That one way to explain this to ourselves and to our patients is inflammation. So anything that inflames the lining of our arteries and can cause problems. A recent study in Jack came out looking at the inflammation in diet. Red meats, processed meats, ultra processed foods, sugar sweetened beverages, refined carbs, processed carbs-- all increased inflammation by some of the inflammatory parameters.

The foods that decreased it-- the fruits, the vegetables, the legumes, the whole grains-- all were great. We know can really help reduce our inflammatory pathways in our arteries. And again, that's one reason. It may be stress, lack of sleep, a lack of exercise, which we all know are pro-inflammatory causes that plays a role also.

FRANCISCO LOPEZ-JIMENEZ: Now, that, I think that's very important, because that helps us to understand that coronary disease-- that the plaques are not just like a fix problem. It's something dynamic. It's something that involves inflammation, density, amount of cholesterol, all those things. So I think we have been just trying to be very simplistic, and that doesn't necessarily help. Well, thank you, Dr. Kopecky, for those very important insights. Thank you for joining us on theheart.org, Medscape cardiology.