Does Exercise Reverse Plaque?

Health

Apr 25

Written By Kevin H

Is there a threshold?

Dr. Kevin Ham, MD

“And let us run with perseverance the race marked out for us, fixing our eyes on Jesus, the author and perfecter of faith.”

Hebrews 12:1-2

I just launched a video of why you should start drinking 50 ml of pomegranate juice each day. I know we hear a lot of things, but I repeat so more people are reminded and my hope is they move to action. If I could stop one heart from aching…

Let me know in the comments of this video if you are drinking pomegranate or not and make sure you subscribe so that you are notified of each video in my channel. https://www.youtube.com/@DrKevinHam

Also watch my Thursday video. It will show you why half the people who are seemingly healthy can have a sudden heart attack. If you are over 50, there is a 91% chance you have plaque in your heart arteries. Also let me know in the comments here whether you knew this or not and if you will get a Calcium CT Heart scan. I’m curious. I’ve had medical doctors ask me for personal consults, which is humbling and my heart goes out to everyone who wants to reverse their diseases.

I am flying to San Francisco today to ride in the Levi Gran Fondo. I’m going to ride a true century mile ride (160 km) with 14,000 ft of elevation (3000 m). I’m excited to meet up with my good friend Michael Woods, who just retired from pro cycling and who can also run a 4 minute mile. He wishes to be the world’s fittest man and is running Ironmans, skiing, biking, running and swimming.

After thinking how I reversed my carotid plaque from May 9, 2025 (Started WFPB Esselstyn diet) to August 19, 2025, when my carotid ultrasound showed that all my plaque was gone and CIMT reduced 53%, I have been trying to understand the mechanism and biochemical pathways this occurred. I have been so focused on diet, that I wondered how much my 3000 km of cycling played a role. I did three Gran Fondo (120+ km) rides last year. Then after my September fondo, I basically stopped riding. My coronary plaque did not really reverse after that, although blood flow improved remarkably. So that has made me curious.

My thought is that high intensity riding accelerated my plaque reversal. So this year I am doubling down and riding four Gran Fondos and running a half marathon. I don’t like running at all but since I am turning 56 years old, I want my bones to be strong and need some impact exercises besides cycling. I also plan to start strength training after my Sept fondo this year and build more muscle so I can retain it as I age. Then I will focus on fasting and less intense exercises for fall and winter months. This is a natural seasonal pattern imho.

So I did a deep dive on exercise studies and plaque. It was so much research that I have to divide it into four parts. Here is the first part looking at the various trials to answer my first question: Is there a threshold intensity and amount of exercise that reverses plaque independently? After this I plan to do a deep dive on fasting and then on multi-modal strategies to reduce plaque, like I am doing:

Dietary x HIIT exercise x Fasting. I call it my Trinity Reversal Flywheel Synergy.

Why High Intensity Interval Exercise?

“Can exercise reverse atherosclerosis?”

Kevin Ham, MD

I have been cycling since 2008 and more seriously since 2014. I can ride with the best and have ridden with my pro team during their rest days on the Tour de France. Riding between Michael Woods and Chris Froome, also a good friend and winner of the Tour de France four times, I felt like I was in the best shape of my life.

Yet I found out that I have severe atherosclerosis. If intense exercise reversed plaque, then shouldn’t my arteries have been healing while I cycled? Why were they so clogged? 77%, 55%, 45% etc.

I even thought initially that because of my intense cycling, maybe it caused my plaque. But I’ve determined that the cause is mostly dietary. When I changed my diet, my plaque reversed. This is what Dr. Esselstyn revealed through his patients, who were ‘end-stage’ heart disease, barely able to walk without getting chest pain or short of breath. But before my dietary changes, I was riding up the Alp mountains in France, Italy and Switzerland. 100,000 m of riding my bike up mountains a year for years! That’s pretty high intensity.

But when my biochemistry became optimal by a complete focused diet that eliminated all added oils and dietary cholesterol, I believe exercise accelerated Reverse Cholesterol Transport (read this article I wrote) in my plaques.

I continually think from first principles and then study how the biochemical pathways work in the body. My degree in Biochemistry and Medicine is delighted to learn with great curiosity and interest and translate this complex biochemical language into something you can relate to so you can be empowered to restore your own health and those around you.

Does studying medicine for four years allow you to heal disease?

Four years of medical school made me a doctor, but if you studied your disease and educated yourself, I believe within a month, you would have enough wisdom and knowledge to start healing yourself. I am spending my spare moments for this very reason. To empower you with health wisdom to reverse disease. We were not taught this in medicine. We were taught to diagnose and manage and sometimes treat disease. Many diseases we do not know or ponder the true cause. Let’s look at some exercise studies to see what’s better: exercise or diet?

What is HIIT?

“I think of my high intensity exercise as a prescriptive pressure wash of my arteries to activate eNOS and nitric oxide, medicine for my blood vessels and to mobilize my HDL to be more functional and activate Reverse Cholesterol Transport, which is one of the greatest health secrets.”

Kevin Ham, MD

Just a note here to describe what HIIT is. It is high intensity, when you exercise at a high intensity such that you cannot speak, huffing and puffing, when your heart rate is more than 80% of your maximum heart rate. A simple measure of your max hr would be 220- your age. So if you are 50 years old, your max hr = 220-50 = 170. I’m 56, but my max hr which should be 220-56=164, is actually 195 beats per min (bpm). So I try to 195*80%=156 bpm. I used to average this hr for 4 hours on my Gran Fondos. Average! After I found out I have blocked arteries, I try to limit my heart rate to 160 bpm and hover between 130-150 bpm, which is what we call zone 2 or tempo training.

So that is the HI in high intensity. Then you must consider the second ‘I” which is Interval. So you have to pace or decide for how long you do this high intensity. There are studies that do 4x4 which is 4 minutes of high intensity repeated four times. In between the repetitions (reps) of high intensity, there is an interval of rest. You need to recover before the next round of HI effort. You’ll know when you are ready when you can breathe comfortably and speak easily. At 150 bpm, I can go 4-6 hours with HIIT. At 130 bpm, I could go even longer. Pretty extreme. So all the HIIT studies are very easy for me as I like to ride 2-4 hours to clear my mind, exercise my eyes. It’s my meditation and hobby.

Top Exercise Studies

“How can we thank all these scientists who pursue their curiosity and passion to discover life’s secrets. I feel so blessed for each scientist. Thank you from the depths of my heart!”

Kevin Ham, MD

1. Vesterbekkmo, 2023.

The first randomized trial of coronary plaque regression from exercise alone.

Published in the European Journal of Preventive Cardiology in 2023, the CENIT trial randomized sixty patients who had recently undergone PCI to either six months of high intensity interval training or usual care. Serial intravascular ultrasound at baseline and six months to measure plaque. The HIIT (high intensity interval training) group showed a between group difference in normalized total atheroma volume of twelve cubic millimeters against controls. Slight regression like cholesterol lowering drugs.

This study was the first randomized trial to show that exercise alone, without additional dietary or pharmacological change, can regress coronary atheroma in humans.

The effect was small in absolute terms. It was also statistically robust, mechanistically coherent, and the first crack in the dogma that only drugs regress plaque.

2. Hambrecht, 1993.

The 2,200 kilocalorie threshold.

Published in the Journal of the American College of Cardiology in 1993 by Rainer Hambrecht and the Heidelberg group, this is the dose response study that quietly defined the exercise prescription for reversal for the next thirty years. Sixty two patients with coronary artery disease were tracked for a year with repeat angiography. The patients were stratified by weekly leisure time physical activity expressed in kilocalories expended.

Below 1500 kilocalories (kcal) a week, lesions progressed.

Above 2200 kcal a week, lesions regressed.

There was a clean dose response, and a clean threshold. 2200 kcal a week translates to about five to six hours of moderate aerobic exercise.Three times what the current American Heart Association baseline recommends. Twice what the average American cardiac rehab program prescribes.

My cycling volume runs at ~8000 kcal a week during the season. More than three times Hambrecht's regression threshold. No wonder I cannot find anyone who has matched the degree and speed of my carotid reversal. I’m an extreme outlier.

But this shows the world what is possible, just like a World Record does. Just like once the 4 minute mile was run by Roger Bannister, runners believed it was possible. I long for many people to break my reversal record for carotid plaques and CIMT of 53% reduction in just three months. I will show by first principles why such reversal is possible, much like a fractured bone healing in just 3 months. This is the basis of my CAST protocol. This is the miraculous healing power within us and in nature and in foods and blood.

3. Ornish, 1990 and 1998.

The Lifestyle Heart Trial.

Published in The Lancet in 1990 with five year follow up in JAMA in 1998, Dean Ornish’s Lifestyle Heart Trial is the most cited reversal experiment in the literature. Forty eight patients with angiographically proven coronary disease, randomized to either a comprehensive lifestyle program or usual care. The lifestyle arm got a ten percent fat vegetarian diet, moderate aerobic exercise, stress management, and group support. Quantitative angiography at baseline, one year, and five years.

At one year, the experimental group showed an average stenosis regression, with eighty two percent of patients improving. The control group on usual care showed progression. By five years, the experimental arm had deepened its regression, and the control arm had accumulated two and a half times the cardiac events.

Two things to notice. First, the exercise component was only three hours per week, and the diet did most of the work. Second, the angiographic changes were small in absolute terms. Mean stenosis fell from roughly forty percent to thirty seven percent at one year.

Meaningful, but modest.

4. Schuler and Niebauer, 1992 and 1997.

The Heidelberg secondary prevention trial.

Published in Circulation in 1992, with six year follow up in 1997, this trial randomized 113 men with stable angina to either a one year intensive low fat diet and exercise program or usual care. Serial angiography at baseline and one and six years.

At one year, 32% of the intervention group showed regression compared with 17% of controls. Progression was 45% versus 48%.

Six years later, the numbers held. Three times the maintenance dose, lower regression rates, but the disease stayed arrested.

The early work suggested that the induction dose of exercise is higher than the maintenance dose, a finding that matches what every endurance athlete in their sixties has figured out empirically.

5. Madssen, 2014.

Twelve weeks to the necrotic core.

Published in the American Journal of Cardiology in 2014, this twelve week trial in 36 post PCI patients used grayscale and radiofrequency intravascular ultrasound to measure plaque composition before and after a short course of aerobic exercise training.

The finding that matters: plaque burden fell by 10.7 percent in treated lesions, and necrotic core volume fell by roughly three percent.

Twelve weeks. That is the shortest regression signal anywhere in the coronary literature. It is the answer to the question every patient asks when they begin. How long until something changes? Three months of real work.

Five coronary trials. Different populations. Different protocols. Different imaging modalities. All pointing at the same finding. Exercise regresses coronary plaque when the dose crosses a threshold that looks something like 2000 kcal a week, sustained over three to twelve months.

What the Trials Say

Exercise reverses plaque. The regression threshold is roughly 2200 kcal per week, which translates to five to six hours of moderate aerobic activity. The modality that matters most is aerobic. The effect is concentrated in people who already have disease. The effect shows up in as little as twelve weeks on imaging.

If that is all you take from this week, it is enough. If you are a man between forty and sixty five with a new CAC score, and a cardiologist who told you to take a statin and walk more, here is what the literature now shows beyond reasonable dispute. The walking is not wrong. The dose is insufficient to reverse plaque. Three hours a week of leisure exercise sits below the regression threshold. Six hours of real aerobic work crosses it.

But that is the trial literature.

I have some ideas for those of you who may find this intensity of exercise difficult.

Focus on reducing your inflammation, oxidation, glycation and LDL lower and exercise will work on helping phase 1 of Reverse Cholesterol Transport via HDL efflux capacity, which means to transport cholesterol out of the plaque.

Even the best statins and PCSK9 cholesterol lowering drugs only reverse plaque by 1%, which is essentially arrest rather than reversal. Even with PCSK9 + statins reducing LDL to 34 mg/dL, reversal does not seem to increase. This means you just need to lower LDL below a certain threshold, which I will cover in Part 3 of this Exercise series.

My own reversal result sits in a place the trial literature does not describe.

“The educated soul can be healthy through its lifestyle, set by its heart and its mind. Heartset and Mindset.”

Kevin Ham, MD

Next week, Part 2: How Much Can Exercise Reduce Plaque?

On Exercise Reversing Plaque.

Arterial plaque reversal can be easier to see, what we call a lead indicator in the carotid neck arteries. That’s what was revealed in my 3 month carotid arterial plaque reversal.

The five published exercise case studies that come closest to mine but none of them come close to my reversal. Why?

My Trinity Reversal Flywheel is running every lever I can find at the same time and explains why three months is not miraculous.

Your Questions

“The educated soul can be healthy through its lifestyle, set by its heart and its mind. Heartset and Mindset.”

Kevin Ham, MD

Questions worth sitting with

1. How many hours a week do you move hard enough that talking hurts?

If the honest answer is under five, you are below the floor where your exercise reverses your plaque meaningfully. Work up towards this as you change your biochemistry.

2. Can you move, hard, for 5 minutes today and repeat each day?

The first 5 minutes are the only 5 minutes that feel impossible. The biology responds to what you do, not what you know.

For Someone You Love

There is someone in your life running their nine steps poorly right now. You thought of them. Send this to them. Your loved ones just need the information to act and a guide to help them.

Keep going. The race is long, the road is beautiful, and the body was built to heal.

Grace, strength and love to you.