The “optimal” diet to prevent artery clogging, and thus avoid cardiovascular disease, consists predominantly of “fruits, vegetables, legumes, nuts, seeds, plant protein and fatty fish,” said 14 medical doctors and other researchers in a review article published in 2022 in the American Journal of Preventive Cardiology.
The authors said that four diets that have gained attention can meet similar guidelines that were issued in 2019: the Mediterranean diet, the DASH diet, a “healthy vegetarian” diet, and the exclusively plant-based, or vegan, diet.
The authors’ recommendations were based on their review of 172 research studies, and constitute a “clinical practice statement” from the American Society for Preventive Cardiology.
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Legumes include beans, peas and peanuts. “Seeds” is another word for grains—such as wheat seeds, from which flour is made, and foods such as rice and oatmeal.
Plant protein can provide all the amino acids your body needs, through any combination of legumes and seeds eaten in the same day, as described in the 1971 bestselling book “Diet for a Small Planet.”
The 14 co-authors recommend reducing consumption of foods containing saturated fat, dietary cholesterol, salt, and refined grain, as well as ultra-processed foods.
Foods with saturated fat include eggs, meats, whole milk, butter, and coconut oil. Dietary cholesterol is found in meats, seafood, poultry, eggs, and dairy products. The most commonly used refined grain is white flour, which is made from wheat grains after the outer bran and the “wheat germ” have been removed.
Ultra-processed food includes calorie-dense foods high in refined flour, sugar and/or fats, such as snacks, treats and many fast food and restaurant offerings. A separate study found that ultra-processed foods were the source of 58% of the calories consumed in America.
The journal article, available for free at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8914096/, is titled “Practical, evidence-based approaches to nutritional modifications to reduce atherosclerotic cardiovascular disease: an American Society for Preventive Cardiology clinical practice statement.”
Low-density lipoproteins (LDL) in the blood “cause atherosclerotic cardiovascular disease,” says a consensus statement from the European Atherosclerosis Society Consensus Panel.
And high LDL cholesterol was found to be the “strongest modifiable risk factor” for artery-clogging, in a study on early-stage artery clogging published in the Journal of the American College of Cardiology.
It’s helpful to understand the effects of various levels of “bad” LDL cholesterol on your arteries, because maintaining the health of your arteries is vital to a long, healthy life.
This is not doom and gloom—it’s more like “an ounce of prevention is worth a pound of cure.”
LDL cholesterol can be reduced in two ways: by taking on additional healthy lifestyle choices, if possible (see chapter 6), and through treatment with a statin medication, which can dramatically lower LDL (see chapter 7).
This chapter presents medical research findings regarding various levels of LDL cholesterol. Nearly all of the research articles discussed are available free online, through the links provided in the footnotes.
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
For “bad” LDL cholesterol, “the lower the better”
Five cardiologists and researchers published an influential article concluding that an LDL level below 70 mg/dL is best. Since the article’s publication in 2004 in The Journal of the American College of Cardiology, it has been cited by more than 600 other journal articles.
The authors compiled data showing that LDL cholesterol ranges from 50 to 70 mg/dL for native hunter-gatherers, healthy human newborn children, primates in their natural habitat, and other wild mammals, “all of whom do not develop atherosclerosis.” Data from clinical trials through 2004, the authors wrote, “suggest” that the progression of artery clogging and the likelihood of heart attacks are minimized when LDL is lowered to less than 70 mg/dL.
The article is titled “Optimal low-density lipoprotein is 50 to 70 mg/dL: lower is better and physiologically normal.”
Several years later, three cardiologists and researchers raised the topic again, posing the question “How low should we go?” when helping patients reduce their LDL level. After reviewing the medical literature, they gave their answer in the title of their article: “LDL cholesterol: the lower the better.” The article was published in 2012 in the journal Medical Clinics of North America.
The authors said, based on their literature review, that the “critical role” of lowering LDL cholesterol in reducing cardiovascular risk “is firmly established.” Lowering the LDL level reduces the likelihood of heart attacks and strokes, they said, while slowing and “even inducing regression” of artery clogging.
For “bad” LDL cholesterol, the lower the longer, the better
A lower LDL level beginning early in life results in a “3-fold greater reduction” in the risk of coronary heart disease than lowering LDL to the same level beginning later in life, according to a study by ten researchers published in 2012 in the Journal of the American College of Cardiology.
The researchers reviewed health outcomes for those with genetic variations giving them low lifetime LDL levels, compared to those treated later in life with a statin medication to reduce their LDL level.
Restating the research findings, Dr. Peter Toth, former president of the American Society for Preventive Cardiology, said that the “risk reduction” from lowering LDL cholesterol “is proportional to both the magnitude of the reduction and the duration of time over which this reduction is sustained,” in a 2020 article published in the American Journal of Preventive Cardiology.
“The reticence for treating patients, including young patients, with statins needs to end,” he said.
At LDL cholesterol levels above 40, the risk of coronary heart disease increases at an ever-steeper rate
Nine researchers teamed with the Coordinating Committee of the National Cholesterol Education Program in a study finding that the risk of coronary heart disease rises with increasing LDL levels, and that the rate of increase in risk “rises more steeply” at higher LDL levels. Their review article reached that finding after analyzing five “major clinical trials” of statin therapy whose results were published between 2001 and 2004.
The article, published in the Journal of the American College of Cardiology, has since been cited by 9700 other studies.
For every 30 mg/dL change in LDL, the authors said that “the data suggest” that the relative risk for coronary heart disease is changed in proportion by about 30%.
Preventive cardiologists aim for an LDL cholesterol level as low as 40 in appropriate patients
Preventive cardiologists aim for much lower levels of LDL, in appropriate patients, than the “below 100” level that is widely considered “optimal” for patients without coronary heart disease or diabetes, according to a standard that dates back to 2005. (This guideline from 2005 is referenced to indicate that the continued use of old guidelines may not be appropriate.)
One preventive cardiologist, Dr. Roger Blumenthal, told the author of this book that “moderate” artery clogging—which can be distinguished from mild artery clogging through a “gold standard” carotid artery ultrasound scan (see chapter 5)—”warrants aggressive lipid lowering therapy and comprehensive risk factor reduction.”
Dr. Blumenthal helped this book’s author lower his LDL number to 40, by prescribing a mid-level dose of a statin medication. He said that an LDL level of 40 “is ideal and levels in that range are more likely to result in modest reversal of some of the plaque buildup, as well as stabilization of the plaques throughout your body.”
“Optimal LDL is 50 to 70”
An influential article described earlier in this chapter compiled evidence on the optimal LDL level, and stated its conclusion in the article’s title: “Optimal low-density lipoprotein is 50 to 70 mg/dL: lower is better and physiologically normal.”
At LDL cholesterol levels below 70 mg/dL, modest regression of existing artery-clogging plaque results
A study by 26 co-authors found that the volume of artery-clogging plaque regresses by up to 2% within the first year in study participants whose LDL level was reduced to 70 mg/dL or below. The study was published in 2015 in the Journal of the American College of Cardiology.
The study presented original research comparing the effects of a statin to the effects of a statin plus the drug ezetimibe, and described three previous studies of the effects of a statin alone.
In all four studies, when the LDL cholesterol level was reduced to 70 or below, the plaque volume was reduced by 0.5% to 2% during the study period.
The authors also cited four research trials which showed that “mean LDL cholesterol levels were closely correlated with median change” in plaque volume.
The authors also found that median LDL levels after treatment with a statin plus ezetimibe were about 8 to 15 points lower than after treatment with a statin alone.
An LDL level below 100 mg/dL is not protective against cardiovascular disease
Eight co-authors analyzed data on 136,905 patients hospitalized with coronary artery disease, and concluded that an LDL level below 100 mg/dL is not protective against cardiovascular disease. The study was published in 2009 in the American Heart Journal.
“Almost half” of those patients had an LDL level at the time of hospital admission below 100 mg/dL, the co-authors found.
Coronary artery disease, also called coronary heart disease, is caused by a buildup of plaque in the coronary arteries, which deliver blood to the heart muscle.
The article suggested that a level of “good” HDL cholesterol above 60 mg/dL was protective against cardiovascular disease, as fewer than 10% of those hospitalized for coronary artery disease had HDL above that level.
An LDL level of 115-120 results in 3x higher risk for “adverse outcomes” than an LDL level of 80-90
Three co-authors found that the likelihood of “adverse outcomes” was 2.97 times higher among people with an LDL level of 115-120, than among people with an LDL level of 80-90, in a study published in 2019 in the Journal of the American Heart Association.
The study examined the risk of cardiovascular disease and all-cause mortality among 3,875 participants, using data collected over an eight-year period.
“Adverse outcomes” were defined as “fatal and non‐fatal atherosclerotic cardiovascular disease (coronary heart disease, stroke, or transient ischemic attack, and intermittent claudication) and death from all causes.”
Most healthy people with LDL above 130 mg/dL had artery clogging by their mid-40s, in one study
Eleven researchers found, in a study of 1,779 middle-aged people without risk factors for cardiovascular disease, that half of had plaque in their arteries, in a study published in 2017 in the Journal of the American College of Cardiology.
The men and women in the study, nearly all in their 40s, each had an LDL level lower than 160, and none of the major risk factors of smoking, family history, high blood pressure or diabetes.
Of these otherwise healthy subjects, 30% had plaque in their arteries supplying blood to the legs, 23% had plaque in their carotid arteries supplying blood to the brain, 17% had plaque in their abdominal aorta, and 11% had calcified plaque in their coronary arteries supplying oxygenated blood to the heart. (The abdominal aorta is the final section of the aorta, the body’s largest artery.)
Researchers tested the first three locations using ultrasound, and the last using a coronary artery calcium test. They found that 23% had plaque in one location, 21% had plaque in two or three locations, and 6% had plaque in four or more locations.
While this study evaluated subjects with no major risk factors, the researchers also noted a previous study they had conducted showing that in a group of middle-aged men and women at “low” risk of cardiovascular disease, 60% had arterial plaque in at least one location, and 41% had plaque in two or more locations.
An editorial comment on the study suggests that arterial imaging at an early stage could be used to guide treatment decisions that could help prevent cardiovascular disease. The study did not include participants with LDL levels above 160 mg/dL, but a study discussed early in this chapter found that for every 30 mg/dL increase in the LDL level, the risk for coronary heart disease increases by about 30%.
A level of “bad” LDL cholesterol below 100 mg/dL is not protective against cardiovascular disease, as found in a study of 136,905 patients hospitalized with coronary artery disease, published in the American Heart Journal. “Almost half” of those patients had an LDL level at the time of hospital admission below 100 mg/dL, said a journal article reporting on the study.
Even so, millions of patients each year with an LDL reading below 100 mg/dL are told that their LDL level is “optimal,” and millions more whose LDL is between 100 and 130 are told their LDL level is “near optimal.”
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
The study suggested that a level of “good” HDL cholesterol above 60 mg/dL was protective against cardiovascular disease, as fewer than 10% of those hospitalized for coronary artery disease had HDL above that level.
The coronary arteries deliver blood to the heart. Coronary artery disease, caused by a buildup of plaque in the arteries, reduces the blood flow to the heart. LDL cholesterol is a major building block of that plaque.
People with plaque in their coronary arteries typically have plaque in other arteries throughout their body. Plaque in the carotid arteries leading to the brain causes strokes, and also vascular dementia due to mini-strokes.
An abstract of the research study is available free online. The study is titled “Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines.”
The study used a database aggregating data from hospitals participating in the “Get With The Guidelines” hospital-based quality improvement initiative, which was developed by the American Heart Association and the American Stroke Association to improve the care of patients with cardiac diseases and stroke.
The volume of artery-clogging plaque has been found to regress by up to 2% within the first year in study participants whose LDL-cholesterol level was reduced to 70 mg/dl or below, according to a study published in the Journal of the American College of Cardiology.
The study presented original research comparing the effects of a statin to the effects of a statin plus the drug ezetimibe, and described three previous studies on the effects of a statin alone.
In all four studies, when the LDL cholesterol level was brought to 70 or below, the plaque volume was reduced by 0.5% to 2% during the study period.
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
The authors also cited four research trials which showed that “mean LDL cholesterol levels were closely correlated with median change” in plaque volume.
In their research study, the authors found that median LDL levels after treatment were about 8 to 15 points lower for participants on a statin plus ezetimibe, compared to those on statin alone.
A “possible mechanism underlying the clinical benefit obtained by dual lipid lowering” (with statin plus ezetimibe), said the authors, “was the suppression of the compensatory enhancement of cholesterol absorption.” They cited a study showing that “mortality increased with increasing levels of the cholesterol absorption marker, the cholestanol-to-cholesterol ratio.”
The authors said their study “found a positive correlation between the suppression of cholesterol absorption markers and coronary plaque regression.”
Evidence of a “direct relationship between the burden of coronary atherosclerosis, its progression, and adverse cardiovascular events” was found in a “large meta-analysis,” the authors added, using the medical term atherosclerosis to refer to artery clogging .
The study, available free online, is titled “Impact of Dual Lipid-Lowering Strategy With Ezetimibe and Atorvastatin on Coronary Plaque Regression in Patients With Percutaneous Coronary Intervention: The Multicenter Randomized Controlled PRECISE-IVUS Trial.”
The likelihood of clogged arteries in patients without symptoms can be far better predicted with a machine learning algorithm based on 12 patient data points, than by the risk scoring systems that doctors currently use, as reported in an article published in the Journal of the American College of Cardiology.
Artery clogging is a progressive disease that ultimately can cause heart attacks, strokes, or dementia. Doctors call the disease atherosclerosis.
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
Researchers developed a machine learning approach they found to be superior to risk scoring methods for cardiovascular disease that are currently used in the U.S. and Europe. One risk-scoring method used in the U.S., for example, when tested against the data set on which the researchers trained their model, assigned an intermediate or high risk score to only 15% of individuals that in fact had early-stage artery clogging at more than one site.
In contrast, the machine learning algorithm, when validated using a data set of patients separate from the data set on which it was trained, had a much higher success rate in identifying individuals with artery clogging, with an “area under the curve” (a measure of the accuracy of a machine learning model) of 0.83, where 1.00 would be perfect.
The researchers trained their machine learning model using data from 3,515 middle aged individuals, for whom data were available from several sources: blood tests; two-dimensional ultrasound scans of the carotid arteries, the abdominal aorta, and the femoral arteries; and coronary artery calcium scoring.
The top five data points found by the machine learning system to be most predictive of artery clogging were, in order: age, average blood sugar over the past three months (“HbA1c”), the ratio of total cholesterol to “good” HDL cholesterol, leukocyte count (a measure of inflammation), and hemoglobin. Also among the top 10 predictors were “bad” LDL cholesterol and systolic blood pressure (the first number in a blood pressure reading). The effects of LDL cholesterol on artery clogging would also be captured by one of the top three data points, the ratio of total cholesterol (including LDL) to HDL cholesterol.
An editorial accompanying the study highlighted the superiority of the researcher’s machine learning model over risk scoring methods used in the U.S. and Europe. It noted, however, that doctors would find that some patient data elements toward the bottom of the list of 12 predictors are not intuitively related to artery clogging. While those predictors could be unrelated to the success of the model when validated against the separate data set, the editorial left open the possibility that there could be “strong import” to those predictors that “we may simply not understand.”
The study, available free online, is titled “Machine Learning Improves Cardiovascular Risk Definition for Young, Asymptomatic Individuals.” The accompanying editorial, also available free, is titled “Transforming Data Into Diagnosis: Exercises for a Computer to Perform and a Physician to Interpret.”
Screening all Americans aged 65 and older with a quick, one-minute carotid ultrasound test could help prevent thousands of strokes per year, says an article published in the Annals of Translational Medicine.
The authors say that a one-minute ultrasound screening test can flag those suspected of having plaque in their carotid arteries causing at least 50% blockage. The carotid arteries carry blood to the brain, and if there is plaque in those arteries and the plaque ruptures, a stroke can result.
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
For those whose screening test indicates possible substantial blockage, a follow-up “formal” duplex ultrasound test can identify those who indeed have 50% blockage of one or both carotid arteries, the authors say. Those individuals could then protect their arteries and stabilize the plaque, the authors say, by electing either vascular surgery or best medical treatment, with the latter presumably including statin therapy.
A quick carotid scan has been used for many years, the authors say, to screen military retirees at the Madigan Army Medical Center in Tacoma, Washington, and has also been used at New York University.
The authors estimate that their proposed screening and follow-up process would find the estimated 8% of Americans aged 65 and older who, according to their research, have carotid artery blockage of at least 50%. These individuals typically would have had no symptoms, and thus no idea that their arteries were partially blocked. Subsequent treatment could reduce the 5-year risk of stroke for these individuals from 20% if left untreated, to less than 3%, they say.
That would prevent 200,000 strokes and yield one-time Medicare savings of $13 billion from avoided direct medical costs, according to earlier research the article cites, which was led by the same principal investigator.
The authors note that stroke is also the leading long-term Medicare expenditure, “fills one-half of nursing homes,” and “has persisted without reduction for decades,” even though the Centers for Disease Control and Prevention says that 80% of strokes could be prevented.
While Medicare in the U.S. does not cover the cost of carotid screening, “it does reimburse for the further evaluation and management of disease found on screening,” the authors say, “which can cover the nominal monetary outlay of a medical facility to provide the initial screening.”
The authors add that at the time of a quick carotid scan, “there is the option of including an ultrasound scan of the abdominal aorta to discover aortic aneurysms prior to rupture, and of scanning the common femoral artery to identify arteriosclerotic plaques which have a high correlation with coronary artery disease and can be a trigger for a cardiac and metabolic evaluation.”
The study, available online for free, is titled “The quick carotid scan for prevention of strokes due to carotid artery disease.”
Artery clogging progressed “significantly” in 41% of a group of apparently healthy middle-aged men and women over a three-year period, found a study published in the Journal of the American College of Cardiology.
The authors note that the progression of artery clogging is linked to heart attacks and strokes, citing earlier research.
Even in those designated as “low risk,” progression of artery clogging was found in 36% of study participants.
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
Progression was measured both as an increase in the number of arterial plaque lesions, and as an increase in the total volume of arterial plaque.
Progression was detected more frequently in peripheral arteries, as measured by 2-dimensional and 3-dimensional ultrasound tests, than in the coronary arteries, as measured by the coronary artery calcium score.
The authors found that higher levels of cholesterol in the blood contributed to progression of artery clogging, and noted this is the risk factor that is the most easily modified.
An editorial comment published with the study noted that artery clogging at more than one site has been found to be “essentially ubiquitous” in those age 60 years and older, with over 90% of men and women of that age group having arterial plaque in at least one site.
The study, available free online, is titled “Short-term progression of multi-territorial subclinical atherosclerosis.” Atherosclerosis is the medical term for artery-clogging, and subclinical means early-stage. The editorial comment, also free online, is titled “Evaluating multi-site atherosclerosis and its progression: ready for prime time?”
Half of middle-aged people without risk factors for cardiovascular disease were found to have plaque in their arteries, in a study published in the Journal of the American College of Cardiology. The men and women in the study, nearly all in their 40s, each had a level of “bad” LDL cholesterol lower than 160, and none of the major risk factors of smoking, family history, high blood pressure or diabetes.
As plaque deposits in arteries grow larger, they can ultimately cause a heart attack, stroke, or dementia.
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
Of the 1,779 healthy subjects, 30% had plaque in their arteries supplying blood to the legs, 23% in their carotid arteries supplying blood to the brain, and 17% in their abdominal aorta, while 11% had calcified plaque in their coronary arteries supplying oxygenated blood to the heart. Researchers tested the first three locations using ultrasound, and the last using a coronary artery calcium test. They found that 23% had plaque in one location, 21% had plaque in two or three locations, and 6% had plaque in four or more locations.
While this study evaluated subjects with no major risk factors, the researchers also noted their previous study showing that in a group of middle-aged men and women at “low” risk of cardiovascular disease, 60% had arterial plaque in at least one location, and 41% had plaque in two or more locations.
In an editorial comment on the study, the journal’s editors suggest that arterial imaging at an early stage could be used to guide treatment decisions that could help prevent cardiovascular disease.
The study, which is available free online, is “Normal LDL-cholesterol levels are associated with subclinical atherosclerosis in the absence of risk factors.” Atherosclerosis is the medical term for artery clogging. The editorial comment, also available free, is titled “Primary prevention of atherosclerosis: time to take a selfie?”
Artery clogging not only causes heart attacks and strokes, but also slows down your brain, according to a study published in the Journal of the American College of Cardiology.
Fortunately, you can get tested for artery clogging, even without a doctor’s order, and if your arteries are getting clogged, a statin drug can slow, stop, or even reverse the process.
Read the free book on “bad” LDL cholesterol, healthy diets, statin safety, and ultrasound artery screening, at the home page: YourArteries.net
The study’s authors evaluated participants who had early-stage plaque in their carotid arteries, which carry blood to the brain. These individuals were found to have “reduced brain metabolism” relative to participants with unclogged arteries. Areas of the brain showing reduced metabolism included areas “known to be affected in dementia.”
The authors pointed to “the need to control cardiovascular risk factors early in life in order to reduce the brain’s midlife vulnerability to future cognitive dysfunction.”
The good news for now is that if you’re middle-aged or older you can obtain, with or without a doctor’s order, a carotid artery ultrasound test to identify the presence or extent of clogging in your carotid arteries.
And if that test shows that the carotid arteries are clogged, a preventive cardiologist can prescribe statins at a dose high enough to aggressively lower your level of “bad” LDL cholesterol, which is a major component of the plaques that clog arteries. A daily statin pill at the right dose can not only protect the brain but can also stabilize the arterial plaques throughout the body, or even shrink existing plaques, lowering the chance of a heart attack or stroke.
Your Arteries 