The liver is the principal site for the synthesis and elimination of lipoproteins circulating in plasma, and alterations in hepatic function influence plasma lipoprotein levels. High HDL-C/T-C and apo A-I/apo B ratios, which are characteristic of a low coronary risk, have been typical of healthy subjects with high microsomal enzyme activity in the liver. Microsomal enzyme inducing drugs such as phenytoin, phenobarbital and carbamazepine, and also alcohol, influence serum lipid and apoprotein concentrations. The inducers increase the concentrations of hepatic microsomal enzyme and apo A-I mRNA, and also proteins and phospholipids. They similarly increase serum HDL-C and apo A-I levels and the HDL-C/LDL-C ratio, powerful protective factors against coronary heart disease. These parameters parallel hepatic protein and phospholipid concentrations, and microsomal enzyme activity as assessed by liver cytochrome P-450 or antipyrine kinetics. Serum LDL-C levels are inversely proportional to hepatic cytochrome P-450 concentrations. Experimental studies indicate that phenobarbital retards cholesterol accumulation in the arterial wall and the formation of atherosclerotic plaque. A decreased mortality rate from coronary heart disease has been reported for subjects who take enzyme inducers, drugs or alcohol, whereas impairment of hepatic microsomal function may promote atherogenesis. In addition to drugs non-pharmacological factors such as dietary constituents and physical exercise may influence hepatic microsomal function and hence improve the serum lipoprotein profile. These observations, which connect microsomal inducers, liver lipids and proteins, serum lipids and apoproteins characteristic of a low risk of atherosclerotic disease and low incidence of coronary deaths, lead to the conclusion that the activation of liver microsomal function can prevent atherogenesis in man.