The possible role of medical management of risk factors as an explanation of international trends in coronary heart disease (CHD) mortality has been reviewed. In general, hypertension, hypercholesterolaemia and smoking are the only risk factors that can be detected and treated, with a significant effect on CHD risk. Few organized international data are available to relate to international CHD trends. It appears that the rates of hypertension detection and control are improving, but for many countries, they are still quite low. Less is known about the relative contribution of lifestyle versus medical management as a cause for blood pressure change. Despite these caveats, it appears that blood pressure control may have played a role in CHD mortality trends; further impact of newer antihypertensive agents is likely. The increased medical management of hyperlipidaemia is a relatively recent phenomenon and is unlikely to explain past CHD trends. However, the increased use of these agents and the introduction of more effective agents makes a future effect on CHD likely. The impact of the medical system on smoking cessation is unclear; medical care providers clearly have a major potential role in smoking cessation, but it is difficult to measure. Thus, it appears that medical management of risk factors has had a minor impact on international CHD trends, though the data are sketchy at best. Future research should better delineate the detection and management of risk factors as an increasingly potent source of risk factor change and subsequent reduced CHD mortality.