An update: I saw the second cardiologist today. He was surprised my score was so high (397) at my age (42) — and especially when he looked at my full blood panel. Total cholesterol at 210, HDL (good) cholesterol is 88; LDL is 110; no diabetes or pre-diabetes; triglyceride level is 43; and CRP of 0.59.

He said he never would have expected someone with this profile to have a score anywhere near this. Gave me hope for a second that maybe, somehow there was an error with the test, but he reinforced that the calcium scan is extremely accurate and reliable.

I told him I was having trouble squaring the dire implications of everything I’ve read about a score like mine with my original cardiologist’s fairly casual attitude toward it. He told me the reality is probably in between my cardiologist’s attitude and my own.

Which means it’s serious. But also that it’s been there for a while; he said it’s probably been building in me for 10 years. Genetics obviously a heavy factor. His main points of emphasis going forward:
* Stress test scheduled for two weeks from now
* Agreed with first cardiologist putting me on Crestor. Said idea will be to smash my LDL below 70 and that if we need to add other drugs (zetia or PCSK-9 inhibitor maybe) into the mix eventually we will. But he was confident that by doing this we will decrease *soft* plaque and limit its future development. Said the calcified plaque will not go away and that the statin might even calcify some more existing plaque and raise my calcium score further.
* Emphasized diet - idea of largely sticking to non-starchy veggies, greens, low carb, some fish and chicken, but try to avoid cheese and cut out fried foods etc. I described what I’d been eating and he thought it was likely helping to push the calcium score up.

My concern is that even with my crappy diet, this calcium score number is crazily high. And it’s not like I have an equally high LDL number that would easily explain it. So I fear that lowering LDL maybe won’t do as much as he’s hoping. But what else can I do? Obviously trying to focus on transitioning to a very different diet. It will be a major adjustment for me, but if it’s what needs to be done I’ll do it.

Of course, that’s my other concern: How do we really know what is and isn’t working? The calcium score won’t be going down, and probably will be going up. I asked him what metrics we should be measuring going forward and he said LDL is the main one - he really believes smashing it under 70 will reverse soft plaques and stop new plaque formation, along with diet. I’m just not sure how this will be measured, again, given that statins will likely raise the calcium score.