Recent primary prevention trials demonstrated that cardiovascular morbidity and mortality benefits are not accompanied by adverse effects on overall mortality and morbidity in cohorts representing plasma cholesterol concentrations observed in the bulk of coronary artery disease. During the past year, further analyses of the West of Scotland Coronary Prevention Study have indicated that benefit requires a 25% reduction of LDL cholesterol and that such treatment is not very expensive when focussed on selected high‐risk individuals. The Air Force/Texas Coronary Artery Prevention Study indicated that benefit is seen in individuals with even lower plasma lipid concentration. Although current treatment with lifestyle and lipid modifying drug management is successful in primary prevention, the unpredictable nature of coronary artery disease and the cost of drugs mitigate against direct application of drug management in persons with relatively low risk, but selective treatment should be undertaken in very high‐risk settings. Future studies need to examine more specific at risk cohorts, test better targeted lipoprotein modification, test more risk factors and also examine whether changes in vascular function or markers of inflammation will predict a better outcome. Curr Opin Lipidol 9:551–556. © 1998