Early intervention to control cardiovascular disease risk factors can result in significant reductions in cardiovascular disease mortality. However, there is a large gap between risk factor management outlined in clinical guidelines and actual patient care, with preventative medication being underused, particularly in low-income countries. Consequently, cardiovascular disease remains the leading cause of mortality. There are several barriers to guideline implementation. First, clinical trial populations are not representative of the at-risk population as a whole. Patients treated in clinical practice are often older with more co-morbidities, making them more difficult to treat. In addition, adverse effects of medication and complex dosing regimens reduce adherence to therapy. The wide choice of guidelines, lack of awareness of the guidelines and a perception that their recommendations are unrealistic, as well as time constraints on the physician and prescription costs, have also been identified as reasons why guideline recommendations are not followed. Strategies to improve adherence to guideline recommendations include research to better define optimal treatment in different patient populations, increased funding for research and guideline dissemination and implementation programmes, policies promoting healthy lifestyles and preventative medicine and physician and patient education. Systemic monitoring of quality of care and outcomes are also important to identify gaps in guideline implementation that could be addressed. A multidisciplinary team approach to risk factor management and telephone/Internet support systems have been shown to improve compliance with lifestyle changes and pharmacotherapy. Overcoming the barriers to implementation of guideline recommendations is key to improving cardiovascular disease prevention.