The role of elevated triglyceride (TG) levels in the pathogenesis of atherosclerosis is controversial. Some studies suggest that TG might play a direct role in the development of vascular disease. Elevated TG levels are also associated with other vascular risk factors and may therefore represent an indirect marker of a high risk state. Another issue is that laboratory measurements of TG levels frequently show a substantial variability. Accumulating epidemiological data show that there is an independent association of TG levels with vascular risk. Some interventional studies also suggested that lowering TG levels might prevent vascular events. It appears that TG might be more important as therapeutic targets against a background of optimal low density lipoprotein cholesterol (LDL-C) levels. In this context, statins that are more effective in reducing TG levels, fibrates that can safely be combined with statins or fixed fibrate and statin combinations, as well as new, better tolerated nicotinic acid formulations might prove to be particularly beneficial.