Recent decades have witnessed significant advances in the use of interventional procedures and medical therapies for relief of symptoms associated with obstructive coronary artery disease (CAD). At the same time, however, little progress has been made in understanding and implementing preventive therapy and risk reduction. Our traditional focus on treatment of severe coronary obstruction has addressed only part of the problem. We now need to adopt a more comprehensive approach aimed at the entire spectrum of atherosclerotic disease. Numerous clinical trials have demonstrated that risk-reduction strategies can produce marked decreases in the incidence of cardiovascular events as well as in total mortality. Despite this strong body of evidence, risk-reduction therapies continue to be underutilized. Comprehensive changes in healthcare delivery systems are needed to ensure that risk-reduction strategies become a routine part of care for patients with cardiovascular disease.