Atherosclerosis does not begin when a risk calculator says it does. Fatty streaks appear in adolescence, and coronary calcium accumulates for decades before the first event, yet primary prevention remains anchored to short-term absolute risk, a framework that systematically overlooks younger patients with a high lifetime burden. This talk reframes atherosclerotic risk as a function of cumulative exposure to atherogenic lipoproteins over time. Drawing on coronary artery calcium trajectories, the natural history of familial hypercholesterolaemia, and the marked benefit of early treatment, it argues that the relevant question is not a patient's risk over the next five years but the exposure they have already accrued. It considers where apolipoprotein B sharpens risk assessment beyond LDL-C, and how a rapidly expanding therapeutic toolkit changes the calculus for acting earlier, all within the realities of New Zealand's funded prescribing environment.