My cholesterol is (frankly) through the roof. My GP wanted to start statins immediately. I pushed back and asked what the big deal was -- my RHR is low, BP is normal, my weight is fine, I have an active lifestyle, and my diet is fine. They explained that the cholesterol might build up a blockage in my heart, and that higher levels meant higher increased risk of that. So I asked whether we could just check and see if that's actually happening, and you can! It's a calcium scoring test, and it cost me $150.
I got a zero, in other words, no blockage at all. When I reviewed my results with a cardiologist, he basically said, "Some people just have high cholesterol, and it's not a problem. You're probably one of them." I also separately got tested for the type of LDL particles, and mine were primarily composed of big, floaty ones that aren't associated with increased risk (or at least that's what the test result notes said).
I'll do the calcium score every 5 years just to keep tabs on it. But thankfully I didn't start a needless medication regimen.
Same story here (though it cost me more - insurance refused to cover it because I did not meet the criteria [0])
LDL while clearly not telling the whole story is a great first line defense at population levels because it's easy and cheap (similar to BMI). If you just throw Statins at everybody with high LDL you're going to improve health outcomes, and historically providers and researchers have considered statins to be effectively "free" (both in actual cost and in side effects).
In developed countries where the equipment for this test is readily available, individual patients should absolutely request it even if paying out of pocket, if for nothing more than their own peace of mind.
I'm a layman but I have come to conclude that the AHA's guidelines on when to recommend the CAC test are too conservative. Definitive knowledge of the underlying pathology (or lack thereof) seems like it would be useful both for people with exceptionally high and exceptionally low scores. Even if in a vast majority of cases the treatment plan would be similar (just give them statins) more knowledge seems better on an individual treatment level.
Calcium scores only reflect calcified plaque - not soft plaque. CTTA is what you need for that.
Particularly for people below ~45 with significant plaque buildup, calcium scores are often 0 or very low, because all of the plaque is soft.
This is one of the reasons CACs aren't used much in younger people - that plaque hasn't yet calcified.
Soft plaque is the dangerous stuff, too - most statins actually calcify plaque, but this stabilizes it and prevents it from rupturing and the chunks entering the bloodstream.
You're probably a "lean mass hyper-responders", a phenotype which is actively investigated, initial paper:
Elevated LDL-cholesterol levels among lean mass hyper-responders on low-carbohydrate ketogenic diets deserve urgent clinical attention and further research
Wow, this might actually be me. When I was doing a protein-heavy, carb-light diet, my numbers matched up with these ranges exactly. High LDL, high HDL over 80, and low triglycerides. Granted that was a good 15 years ago, but still. Glad to have something specific to look for.
You're missing a key fact, which others have noted, but I would phrase it differently.
Calcium is the end-stage of atherosclerosis. In other words, only advanced atherosclerosis has calcium. The electron beam CT test can, therefore, read zero in people with extensive atherosclerosis, if it is still in the earlier stages. As others note, even early atherosclerosis is bad.
That is why insurance doesn't cover electron beam CT -- it's a crappy test. It provides no reassurance if it's negative, and on a population scale the LDL is far more cost effective and convenient to identify people who need statins.
You might look back at studies from the early statin days, like AFCAPS/TexCAPS, which looked at healthy people like you, whose only risk factor was high cholesterol. The ones who got even the primitive statins of the day lowered their risk of a first coronary event by 37%. That doesn't even tell the whole story, because atherosclerosis can affect any artery in the body. You want your kidneys, eyes, ears, brain, legs, and penis (when present) to work well to the end of your days. Atherosclerosis is a terrible disease.
I got a zero, in other words, no blockage at all. When I reviewed my results with a cardiologist, he basically said, "Some people just have high cholesterol, and it's not a problem. You're probably one of them." I also separately got tested for the type of LDL particles, and mine were primarily composed of big, floaty ones that aren't associated with increased risk (or at least that's what the test result notes said).
I'll do the calcium score every 5 years just to keep tabs on it. But thankfully I didn't start a needless medication regimen.