That's a great question! The process of athrosclorosis is extremely complicated and there are many elements that are still a mystery. I certainly may have familial hypercholesterolemia, although I don't have the FH mutations. There maybe hundreds or even thousands of FH subtypes. I don't think there is one answer to this important question, it may be a different process for different people. I do feel that there are common culprits/contributors like toxic environments, poor nutrician, hypertension, stress, high blood pressure. High LDL could be a factor for some, but there are people that have high LDL and a zero calcium score. Oxidized LDL seems to be a more likely villain. It seems that damage to the glycocalyx commonly precedes damage to the vascular endothelium. Diet could definitely be a factor for some, for me personally I can eat a low carb diet or a low fat diet with very little change in my blood work. Our body makes 80%-85% of the cholesterol. Statins may help some people but it may not be because they lower LDL, they also lower inflammation and may help prevent glycocalyx damage and stabilize plaque. In some people statins will actually increase the calcium score (stabilizing plaque). Then there is the coagulation factor. There is still so much to be discovered.