Hi there,
"Did none of it work?"
A patient asks me this after doing nearly everything right. ApoB is way down, blood pressure is controlled, they're stronger and sleeping better.
Then the repeat calcium (CAC) scan comes back with a higher score.
I'm hearing this question more this year, and the new cholesterol guideline is part of the reason. The ACC and AHA guideline released in March uses your calcium score to set your LDL goal: any calcium means aiming below 100, and lower as the score climbs. More people will get a calcium score, and many will be tempted to repeat it.
Usually, the plan did work. Here's why, and what this year's research adds.
The short version
A rising calcium score often means plaque is stabilizing, not that treatment failed.
The best evidence for shrinking plaque comes from lowering ApoB/LDL hard and early.
Lifestyle helps a lot, but it can't override your genes.
Skip nattokinase, K2 "artery cleaners", chelation and yearly scans to grade yourself.
"Reversal" can mean five different things
When someone says they reversed their plaque, ask what actually changed:
Progression: the plaque stopped growing.
Regression: a scan showed less plaque.
Stability: less fat and a thicker cap, so it's less likely to rupture.
Function: the artery widens and carries blood better.
Outcomes: fewer heart attacks and strokes.
The last result is what actually matters. Most heart attacks come from a plaque that ruptures and clots, not from an artery slowly closing, so shrinking is only one way to get safer.
These don't always change in the same direction. This year's ESSENCE-TIMI 73b imaging study is a good example. The drug olezarsen cut triglycerides by about 64% and remnant cholesterol by about 72%. After a year, soft plaque was no different from placebo. My read: ApoB, the count of plaque-forming particles, fell only about 16%.
A better lab number isn't proof the plaque changed.
Why your calcium score can rise while you get safer
Calcium in the arteries usually doesn't go away. The calcium score multiplies the size of each calcified spot by how dense it is.
Statins make plaque denser: less soft, fatty material and more hard calcium. Because the score rewards density, a more stable plaque can produce a higher number. In the MESA study, more calcium meant more risk, but at the same amount, denser calcium was linked to less risk.
That doesn't make a high score good. A big score still means disease. But the calcium score is a risk marker, not a progress bar, so I don't repeat it every year to grade anyone.
If your calcium score went up while your ApoB and blood pressure were on target, I wouldn't change course to chase the number. If you need to know what's happening underneath, a quantitative CCTA can show whether the soft plaque is shrinking while the calcium hardens.
What actually shrinks plaque
Lowering ApoB/LDL, hard and early. The plaque trials agree:
ASTEROID: intensive rosuvastatin took LDL from about 130 to 61 and shrank plaque.
GLAGOV: adding evolocumab took LDL into the 30s. 64% of patients had regression, versus 47% on a statin alone.
PACMAN-AMI: after a heart attack, alirocumab meant less plaque and a thicker cap.
The shrinkage is small, about one percentage point of plaque volume. The drop in cardiovascular events is much more significant.
Across 170,000 trial participants, every 39 mg/dL drop in LDL meant about 22% fewer major events (heart attacks, strokes, stents and bypasses). How low you go matters, and so does how long you stay there.
In January, VESALIUS-CV showed this holds before a first event, too. In 12,257 people with atherosclerosis or diabetes but no prior heart attack or stroke, adding evolocumab cut first heart attacks, strokes and coronary deaths from 8.0% to 6.2% over five years.
The newest option: on July 17 the FDA approved the first PCSK9 pill, enlicitide (Lipfendra). Until now this drug class came only as injections. It cut LDL by about 56 to 59% on top of statins. Its own outcome trial isn't finished, so the proof that it prevents heart attacks still comes from the drug class, not from this pill.
What lifestyle can do, and where it hits a wall
Lifestyle intervention is real medicine. In the DISCO-CT trial, people with early plaque who followed a dietitian-guided DASH diet on top of good medical care lost more soft plaque than people on medical care alone, though total plaque didn't differ. Mediterranean eating cut heart events in the PREDIMED and CORDIOPREV trials. Exercise improves how arteries work, often before any scan changes. And quitting smoking beats any scan you can buy.
But some of my most careful patients still have high LDL or Lp(a) because of their genes. Needing medication isn't failure.
When I saw my own LDL of 192, I was shocked. It was worse than nearly every lipid panel I'd seen in my primary care clinic, including in patients who lived far less healthy lives than I did. I'm on lipid-lowering medication now. I'm also more careful about saturated fat and I exercise more, though in my case lifestyle was less of a factor than my underlying genetics.
Shortcuts I'd skip
A few notes from me:
Berberine lowering LDL a little is an argument for a drug with actual outcome data.
Vitamin K2: I've changed my mind on this one. I used to recommend it with D3 all the time!
Red yeast rice: in my view, it's unacceptably risky if you can get a prescription statin instead.
Calcium scans: if you're doing a lot to change your plaque, a CCTA with AI will give you a clearer view, and it still doesn't have to be yearly.
The scoreboard I'd use instead
Know your drivers: ApoB, Lp(a) (test it once), blood pressure, glucose, kidney function, sleep apnea and family history.
Set targets for your risk, not a generic range.
Pick treatments you'll stick with, lifestyle and medication together.
Scan only when it changes a decision. Neither a calcium score nor a CCTA is a yearly report card.
Track what the scan misses: ApoB, blood pressure, fitness, and whether you're actually following the plan.
Not sure which heart test answers your question? My free heart-test guide walks through it.
Quick hits
🫀 Statins hardened the calcium, again. In a new analysis of 338 people with a family history of early heart disease, statins shifted plaque calcium toward denser, more stable forms, most when LDL fell 30% or more. It's a scan finding, not proof of fewer heart attacks, but it's the pattern behind today's main story.
🧬 Lowering Lp(a) didn't cut heart events, at least with this drug. Pelacarsen lowered Lp(a) but missed its main goal in 8,323 people with heart disease. Other Lp(a) drugs are still in outcome trials, and I'd still test yours once.
📊 A calcium score didn't beat the usual risk math. In CorCal Outcomes, starting statins based on a calcium score made no difference in heart events compared with standard risk calculators. Events were lower than expected, so the trial couldn't rule out a smaller benefit.
🩺 Lower blood pressure helps, kidney disease or not. Across 27 trials and 88,830 adults, every 10-point drop in systolic pressure cut major heart events by 15%, with or without kidney disease. Kidney numbers dipped on stronger treatment, but kidney failure didn't rise.
💉 The flu shot is heart medicine too. In the IAMI trial, people vaccinated right after a heart attack or stent had fewer deaths, heart attacks or stent clots over a year: 5.3% vs 7.2% on placebo. If you have heart disease, it's an easy win this month.
🧪 Peptide comments close Friday. HHS takes public comments on its peptide draft until November 13. Monday's Letter covers what it does and doesn't change.
Your turn. I'll share the results, and what I'd do, in next week's Letter.
Your calcium score went from 120 to 140 on a statin. Your ApoB is at goal. What would you do?
And one quick favor, so I can write for the people actually reading this: two questions.
What best describes you?
What else do you read, watch or listen to for health? Hit reply and tell me.
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Talk soon, Hillary Lin, MD
P.S. If you're building something in health, I also write The Curator Stack for founders. My latest issue is on which AI tools can touch patient data. Join the Stack here.
From The Longevity Show
If this issue got you thinking about your own heart tests, this episode walks through what each one is really telling you.
Where to find me
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Educational content only, not personal medical advice. Patient examples are composites.
