Background Observational studies have demonstrated that triglycerides are an independent risk factor for coronary heart disease. Atherothrombosis may be mediated by uptake and incorporation of triglyceride-rich lipoproteins by macrophages and through an association with small, dense LDL and HDL particles. There are considerable data that lowering LDL cholesterol reduces cardiovascular events. However, the importance of triglyceride lowering remains elusive. Methods A summary of major arteriographic and clinical end point trials is reviewed. Studies evaluating various strategies, including dietary and hygienic measures as well as pharmacologic therapies, are discussed. Results Dietary reduction of saturated fat, coupled with aerobic activity, reduces triglyceride levels approximately 20% to 24%. Omega-3 fatty acids may also reduce triglyceride levels appreciably. Effective pharmacologic therapies that lower triglyceride levels include nicotinic acid (20% to 40%), fibrates (20% to 55%), and statins (10% to 30%). Nevertheless, an independent benefit of triglyceride lowering on coronary event rate has not been demonstrated. Conclusions There are little data that triglyceride reduction improves cardiovascular event rate. In contrast, lowering LDL cholesterol and, more recently, raising HDL cholesterol are proven therapies in coronary heart disease prevention. As such, these modalities remain the top priority in the management of dyslipidemia with triglyceride reduction as an adjunctive consideration. (Am Heart J 2000;140:232-40.)