The National Cholesterol Education Program: ATP II (NCEP) has established new aggressive goals for lipid treatment in patients with coronary artery disease (CAD), which reduces recurrent CAD events in clinical trials. It is unknown how often these goals are actually achieved in the primary care setting, or whether these guidelines have influenced treatment. We studied 1,934 veterans with known CAD having lipid testing between 1991-93 and followed for 22.3 +/- 10.2 (mean +/- sd) months, 1 year after release of NCEP:ATP II guidelines. Dyslipidemia (LDL > 130, TG > 200, or HDL < 35) was initially present in 1580 patients (82%). Mean LDL was 144 +/- 48, total cholesterol 216 +/- 46, and HDL 40 +/- 16 mg/dl. In 61% LDL was > 130, the previous NCEP target. At followup 84% of patients failed to meet the revised NCEP target (LDL < 100) and 59% had an LDL > 130. Mean followup lipids were unchanged from initial values. A mean of 4.5 +/- 3.7 lipid profiles were drawn per patient. Lipid-lowering drugs were used in 32%, but these patients did not reach LDL goal any more often than those not on drugs. Reasons for not achieving a LDL < 100 were failure to use lipid drugs (37%), inadequate dose and/or dose-limiting side effects when drugs were used (24%), and failure to retest lipids (22%).Nearly all in this high risk population have dyslipidemia requiring intervention by NCEP criteria; few reach target LDL levels, and lipid treatment did not improve after 2 year followup. Substantial cost and effort are expended in testing and attempting to treat dyslipidemic CAD patients in the primary care setting, but fail to achieve optimum lipid lowering. More effective treatment strategies must be implemented before the benefits of lipid lowering can be achieved outside of clinical trials.