@leeosteo, @loplady

Here are the labs and tests that were part of my evaluation. Keep in mind that my doctors were reviewing an existing diagnosis of coronary artery disease established 2yrs prior to my HRT consultation, so my list might be more extensive than what is required for someone with a clean scan:
Labs: full lipid panel, ApoB (Apolipoprotein B), Lp(a) -a genetic marker, HbA1c, hs-CRP, and CMP
Tests: Echocardiogram, CAC Scan (my score is 38), ultrasound of the carotid artery, AAA (Abdominal Aortic Aneurysm), and peripheral arteries (all negative).

I did not do a CCTA or any type of stress tests since both specialists felt they weren't necessary in my case. My situation is a bit ironic: I have no family history of CVD or metabolic disease, but my past diet habits led to this early plaque built-up and calcification. You, on the other hand, have a clean CAC score at an older age despite your family history.

HRT-related cardiovascular risk follows a 'timing hypothesis': clinical trials suggest it is safest and most beneficial when started within 10 yrs of menopause (or before 60). Breast cancer risk, however, is primarily driven by the duration of use, dosage, and the type of hormone prescribed based on large observational studies.

Family history of breast cancer isn't an automatic contraindication. For example, triple-negative breast cancer isn't hormone-sensitive, so HRT doesn't carry the same concern. There are also multigene panels beyond just BRCA1&2 available nowadays. Seeking a specialist well-versed in detailed risk assessment (like a medical oncologist or NAMS-certified menopause specialist) might be the key.

Here is the link for Tyler-Cuzick: https://magview.com/ibis-risk-calculator/

Good luck!

p.s., my LDL-c has been maintained under my specialists' target (under 50) for a number of years now. This, combined with my -ve ultrasounds, lack of family history and other notable medical conditions, was likely a major factor in getting the "green light" for HRT despite of a +ve cac score and being 61 at the time.