Hypercholesterolaemia is a major risk factor for the development of atherosclerosis which, in turn, underlies most ischaemic heart disease (IHD). This review deals briefly with the pathophysiology of lipids in humans and follows with a discussion of current lipid-lowering therapies. In those patients with a history of myocardial infarction (MI) or unstable angina, appropriate lipid-lowering therapy has been convincingly shown to reduce not only cardiac events but also overall mortality. The advent of the HMG CoA reductase inhibitors in the late 1980s has had a revolutionary impact in the clinical management of hypercholesterolaemia, not only because of their efficacy but especially because they are well-tolerated. The use of other treatments such as the fibrates and bile acid resins are also discussed. Given the successful use of the statins, it is felt that an emergence of a different class of LDL-cholesterol lowering compound is unlikely in the near future and rather that compounds which can increase HDL-cholesterol while lowering LDL will be of greater impact. There may also be a shifting trend towards such naturally occurring compounds as plant stanols and phytoestrogens.