Since its introduction more than 10 years agod, LDL‐apheresis has gained much interest and has proven its clinical utility in patients who cannot be adequately treated by diet and drug therapy alone. A number of clinical studies have clearly demonstrated that regular LDL‐apheresis not only favourably influences the progression of coronary artery disease, but also decreases the incidence of cardiovascular events and prolongs survival time of coronary patients at high risk. Both hypercholesterolemia and hyperfibrinogenemia show a high prevalence in heart transplant recipients and seem to cause direct effects on survival time. Heparin‐mediated extracorporeal LDL‐precipitation‐LDL‐apheresis has proven to be very successful in this group of patients, which may be caused by the simultaneous removal of LDL, lipoprotein (a) and fibrinogen, and also because LDL‐apheresis decreases the susceptibility of LDL to oxidation. In addition, there is clear clinical and experimental evidence that LDL‐apheresis rapidly improves the endothelial‐mediated vasomotion. Not unexpectedly, there are differences in specificity and side‐effects between the systems used and these deserve more attention for future routine clinical use. Curr Opin Lipidol 9:521–526. © 1998 Lippincott Williams & Wilkins