The initial serious manifestation of Familial Hypercholesterolemia (FH) is often angina or heart attack, with characteristic soft, cholesterol-rich plaques in proximal coronary arteries posing a high risk of sudden death if ruptured.

“then very often especially in the old days the first really serious manifestation is either angina or a heart attack and one of the things that is so dangerous about this disorder is that it's the plaque that you get in FH is a soft plaque it's a cholesterol-rich large plaque that is very often proximal in the coronary arteries meaning that if a black like that burst you either have an occlusion of your entire LED or you have a main stem occlusion which kills you right on the spot you know sudden death”