OBJECTIVES: While published guidelines for managing hyperlipidemia are well publicized, many patients either are not treated or managed suboptimally. This study examined physicians' knowledge, attitudes and practices in managing primary care patients with elevated serum lipid levels. METHODS: An online questionnaire was developed, pilot tested, and administered to 98 primary care physicians with patients at varying risk for coronary heart disease (CHD.) The questionnaire was administered during a two week period. Questions assessed physician's knowledge of current national guidelines for managing patients with hyperlipidemia, use of various lipid lowering therapies, lifestyle interventions to lower serum lipids, use of national guidelines, and treatment practice for patients at varying risk for CHD. Questions used a 5 point Likert scale (with 1 indicating very important and 5 of little to no importance). RESULTS: The questionnaire had an 80% response rate. Most physicians reported following published national cholesterol guidelines all (15%) or most (77%) of the time. Physicians perceived themselves to be very knowledgeable about current published national guidelines for the management of elevated serum cholesterol levels (53%), lifestyle interventions to lower serum lipids (50%), and lipid lowering therapies (49%); they were considerably less knowledgeable (19%) about costs of lipid lowering medications. Major concerns with the use of published national guidelines included lack of patient compliance (moderately to strongly agree) (72%), and lack of time to adequately use guidelines during office visits (22%). CONCLUSIONS: Despite physician guideline awareness, achieving desirable serum lipid levels in the patient population remains an elusive target. Current provider education efforts are not sufficient. As more managed care organizations and group practices implement electronic medical records, the use of evidence based treatment algorithms should result in better management of cardiovascular risk factors, including elevated LDL levels, in general practice populations as well as targeted high risk groups.