Over the past several years, results of clinical trials of lipid lowering have increased our understanding of the pathophysiology of coronary atherosclerosis and ischemia. Evidence is accumulating that cholesterol lowering has potential anti-ischemic effects and may have immediate consequences that have a favorable impact on coronary events, possibly even acute coronary syndromes. Yet, less than one half of all patients hospitalized for acute coronary syndromes have their cardiovascular risks appropriately modified. The results of recent statin trials provide impetus for the implementation of aggressive risk-reduction strategies in patients with coronary atherosclerosis, including those with recent acute coronary syndromes. Prevention is now a viable therapeutic goal.