I believe this is true, as far as ASCVD goes. This is the analogy of somebody being tied down to the train tracks and simply getting them off the tracks extends their life. It seems to be simple enough that of you bottom out ApoB (and others like Lp(a)) then you basically won’t develop ASCVD in your expected lifetime.
However, other variables like inflammation, blood pressure etc matter for overall cardiovascular health. For example, high blood pressure alone can cause ventricular wall thickening etc. Infections can cause myocarditis. There’s plenty of CVD outside of ASCVD. But you’re right - I think confusing comes from the fact that atherosclerosis is so common and predominant that ASCVD becomes equated with all CVD.
There honestly isn’t. The science is pretty damn settled, particularly at the population level. What makes a difference is the individual level. Some people, for whatever reason, are very resistant to atherosclerosis. They can have mega high LDL-C/Apo-B and zero atherosclerosis. And some people can generate plaque with LDL-C of 70, which is below most current therapeutic targets. However, the overall science of how lipids are involved in atherosclerosis is not really subject to back and forth - it gets more solidified each year.
I remember in your case that you are 70-something, have high LDL, but a relatively low calcium score for your age, plus a healthy lifestyle. So in your specific case there is less argument in favour of statins, since you seem to not accumulate much plaque. However, there are users here in their 40s with positive calcium scores, and they’re hopefully expecting to live another 40, 50 or 60 years. For them, statins (or BA, PCSK9i, Ezetimibe etc) should be a no-brainer.
In your case, if I were you, I’d still look to bring down that LDL-C level through some easily-available pharmacology. A CAC of 108 is not zero, and CAC only tells us about advanced disease. ASCVD is responsible for ~50% of all deaths, and you already have it to some extent. Thus, I’d look to minimizing that risk as much as possible, since you’re presumably hoping to be alive 20 years from now.
