This ESC scientific statement provides a comprehensive synthesis of imaging-based evidence on the pharmacological modulation of coronary atherosclerosis, highlighting that plaque partial regression is achievable, if rather modest and therapy-dependent. High-intensity statins remain the cornerstone, with consistent dose-dependent effects on plaque volume and stabilisation. PCSK9 inhibitors demonstrate additional, incremental regression and favourable compositional changes when added to standard lipid-lowering therapy. In contrast, data on anti-inflammatory therapies are more heterogeneous, with variable effects across imaging and clinical settings. Importantly, the document underscores the persistent gap between imaging-defined plaque modification and documented clinical benefit. By shifting the focus from risk-factor control to direct plaque targeting, the document also exposes the limitations of plaque regression as a surrogate endpoint and the need for more prospective data.
