Cardiovascular diseases account for about half of total mortality in industrialised societies. This figure has declined only slightly and in few countries over the past few decades, which is disturbing in view of our increasing insight into long-term risk factors of coronary heart disease and the dramatic improvement in the acute therapy of its manifestations. One important reason for this is the high fatality during the initial hours of a coronary event, i.e. before medical treatment can be provided. Approximately one quarter of all patients suffering an acute cardiac event die prior to admission to hospital. As a result, the focus of current research has shifted from after-the-fact therapy to the triggering phase of acute coronary disease. Epidemiological observations of recent trends and newly identified determinants of coronary disease and the results of substantial pathophysiological studies of the conversion from chronic coronary disease to an acute event provide the basis for new hypotheses about the triggering mechanisms. The ultimate goal is to design more effective preventive strategies for these deadly diseases. The present extensive summary of important scientific and clinical developments in the study of the triggering and prevention of coronary syndromes that have been seen over the last ten years contains the contributions of leading experts in the field. It presents a cooperative, balanced view derived from physicians and researchers in the U.S. and Europe.