OBJECTIVES: Understand the factors associated with failing to achieve NCEP ATP III low-density-lipoprotein cholesterol (LDL-C) goals. METHODS:   Adults ≥18 years of age, initiating statins (atorvastatin, rosuvastatin, simvastatin, pravastatin, fluvastatin, or lovastatin) between 1/1/2009 through 9/30/2009 with no use of the index statin 3 months prior to initiation were identified via retrospective physician survey/chart extraction. Risk factors associated with failing to achieve LDL-C goal were identified using 1) direct physician assessment and 2) logistic regression analysis. Physician assessment was reported for all patients as well as 4 subgroups (patients with CHD, type 2 diabetes without CHD, other CHD risk equivalents excluding diabetes, and multiple [≥3] concomitant therapies). RESULTS:   A cohort of 869 patients was identified (mean age 52 years). Twenty-four percent of patients were unable to achieve LDL-C goal within 1 year after statin initiation. Based on physician assessment, 45% did not achieve LDL-C goal due to poor adherence to statin therapy, 35% for lifestyle changes, 26% for no/slow improvement on statin therapy, and 14% for adverse events (e.g., myalgia) with statin therapy. Reasons (poor adherence to statin therapy, lifestyle changes, no/slow improvement, and adverse events) for not achieving LDL-C goal differed among subgroups: CHD subgroup 36%, 38%, 26%, 14%; diabetes subgroup 32%, 24%, 32%, 21%; other CHD risk equivalents subgroup 39%, 29%, 50%, 18%; multiple concomitant therapies subgroup 36%, 30%, 39%, 15%. The logistic regression model indicated index statin, older age, non-adherence to statin, having diabetes or other CHD risk equivalents, smoking, high baseline LDL-C, and low baseline HDL-C were significantly (P<0.05) associated with failing to achieve LDL-C goals. CONCLUSIONS:   This retrospective chart review identified poor adherence to statin therapy, underlying clinical conditions (diabetes or other CHD risk equivalents), adverse events such as myalgia, smoking, baseline high LDL-C, and low HDL-C as factors associated with  failure to achieve LDL-C goals.