In a follow up of elderly Framingham men and women, and after multivariate adjustment, the total/high-density lipoprotein-cholesterol ratio remained highly associated with the incidence of coronary heart disease in both sexes, whereas total cholesterol level was associated with coronary heart disease only in women. Whereas total cholesterol values decline in the very elderly, and the association of coronary heart disease with total cholesterol level alone is weaker in the elderly than among those of middle age, the total/high-density lipoprotein-cholesterol ratio remains a strong predictor of coronary heart disease. In assessing the elderly for coronary risk, lipid measurements should include high-density lipoprotein-cholesterol and cholesterol determinations.