The relationship between the evolution of ischemic heart disease and changes in lipid profile was investigated in 115 of 11,875 patients underwent coronary angiography (CAG). The 115 patients had no significant stenosis on initial CAG and underwent repeat CAG for several reasons. Changes in lipid profile and other coronary risk factors were compared in 30 patients who developed ischemic cardiac events (Group E) and 85 patients who did not (Group NE). Ischemic cardiac events were defined as ischemic chest symptoms with ST-T changes or appearance of significant angiographic stenosis. At initial CAG, smoking was significantly more common in Group E (23.3% vs 4.7%, p < 0.01) and high-density lipoprotein cholesterol was significantly lower in Group E (42 +/- 11 vs 48 +/- 15 mg/dl, p < 0.05). At repeat CAG, smoking continued to be significantly more common in Group E (26.7% vs 10.6%, p < 0.05), and serum cholesterol (219 +/- 36 vs 193 +/- 34 mg/dl, p < 0.01) and low-density lipoprotein cholesterol (141 +/- 33 vs 115 +/- 29 mg/dl, p < 0.01) were also significantly higher in Group E. Multivariate analysis revealed only the increase of serum cholesterol at repeat CAG was a significant factor in the evolution of coronary artery disease (p = 0.026). Two patients from Group E died of cardiac causes within 1 year after repeat CAG but no patients in Group NE died (6.7% vs 0%, p < 0.05). Increased serum cholesterol level is related to the evolution of ischemic heart disease and cardiac death.