Just in case anyone has been following this and finding it useful (or finds this thread later), I wanted to post one more update on my situation. I think this will be the last one.

Basically, I have:

* A lipid profile that looks completely normal (and even good), except for *slightly* elevated LDL

* No direct (parents/sibling) family history of heart attack, but there is some heart disease further out in the family tree (great-uncles on my dad's side, diabetes in my grandfather, bypass surgery for my dad's brother)

* A 10-year event risk score of <2% on all traditional calculators -- meaning that I never met any criteria for getting a calcium test and no doctor ever looked at my bloodwork and thought I might have any issues with my heart

* Nonetheless, a cardiologist this spring suggested that -- for peace of mind -- I pay 100 bucks and take a calcium test. He expected it would come back 0. Instead it came back 397.

* Since then, I have been on a journey to try to understand my situation/prognosis. I was placed on a statin, which almost immediately brought my lipid levels to the target range (<70 LDL), passed a stress test with an echo, and had a CT-angiogram. I've also made significant changes to my diet. Pretty much terrified of eating sugar, meat, dairy, processed/fried foods etc.

I have also consulted with several cardiologists and have gotten some mixed signals. The main cardiologist, who initially suggested the CAC test, is well-credentialed and experienced and has been adamant since the score came back that I shouldn't be worrying. He insists that I don't have a problem, only the potential for one, and that aggressive statin use and diet/exercise will prevent me from having a problem. He said that when the initial calcium score came back and said it even more adamantly this week when the CT-angiogram results came back. In fact, he told me that the angiogram showed only a minimal amount of plaque in my arteries, nothing that he would even consider out of the ordinary for someone my age. I was encouraged by his assessment but also confused, since none of the material I've read has suggested that a sky-high CAC score is as easily treatable as he says it is.

So I followed up with another very well-credentialed cardiologist yesterday. He reviewed all of the tests and materials. Overall, he agreed with the approach of aggressive statin use combined with diet/exercise and did talk about this as a condition that I can potentially live a long life with - provided that we arrest the plaque progression now. But he disagreed with the other cardiologist's assessment that the CT-angiogram only showed "minimal" plaque in my arteries. He said it looks to him like a significant amount, especially for someone my age. So while it's good news that the angiogram showed nothing even close to a blockage, it did show plaque that could at some point rupture and cause an event. He stressed that my day to day odds of this are "negligible," but I then asked him if he could put some numbers on what my risks are. He said that my case is unusual in that -- as I mentioned -- there's nothing in my lipid profile that would normally even prompt a calcium test and that without the CAC score, he would calculate my 10-year risk for an event at less than 1%. But with the score of 397 factored in, he says it takes my risk up to 8-9%. I asked what statin use could lower it too. He guessed that we could get it back closer to 3%, but then actually used his risk calculator and told me the number is 5%.

I think I am going to accept this as the last word on what I'm dealing with. I found this second cardiologist to be very knowledgeable and willing to explain and talk through everything. So I think that is my risk: There is a 1 in 20 chance that I will have a heart attack in the next 10 years. For someone without my CAC score, it would be more like 1 in 120. This seems much more realistic to me than the first cardiologist's adamant/data-free assertions that "we know how to treat this and there's nothing for you to be worrying about here." The reality is that I have about a 6-fold increased risk of a heart attack over someone my age with no CAC. Overall, of course, I have a 95% chance of no heart attack in the next 10 years too, and that's what the cardiologist I saw yesterday wanted to stress. So my challenge will now be try to think of it that way and move forward. But it will be tough for me. When I think of 1 in 20, it doesn't sound so remote. I imagine being one of 20 people lined up in front of an execution squad, where they get to pick one to kill. I'd be very uneasy that it would be me. A lot more uneasy than if I was 1 of 120 people. That's the kind of stuff going through my mind right now. The only thing I wish I had asked him before leaving was if that computed 5% risk (which is based on statin use) might be further reduced with diet/exercise. I imagine the answer is that it can't hurt, but obviously I'd love if there might be a quantifiable reduction. Mentally, I could probably process a 2-3% risk much better than a 5% risk.

So that's that. I'm 42. I have atherosclerosis. It's a mystery why I got it. And the plaque load I have is extensive for someone my age. I will follow the guidance om statins and hope that my current dedication to a healthy diet/exercise regimen will persist. But even with this, there's no getting around the plaque that I already have. It's there, it could rupture for reasons unknown at any minute, and the chance that it will in the next 10 years -- while low in the grand scheme of things -- is much higher for me than for most other 42 year olds. I've just known of too many "healthy" people in their 40s and early 50s having sudden heart attacks; it will be difficult for me to try to live my life with this knowledge. It's just the way I'm wired, I think.

Good luck to everyone here dealing with high CAC issues and to any others who might read this in the future.