Remodelling is the adaptive or maladaptive response to cardiac overload or injury resulting in changes of size and function of the heart. The final pathway of maladaptive or adverse cardiac remodelling is the evolution of heart failure or sudden cardiac death. In coronary artery disease, ischemic injury leads to changes in the cellular and extra-cellular architecture of the infarcted and non-infarcted region resulting in cavity enlargement and loss of contractility of the entire heart. During the last three decades, potential therapeutic concepts have been established and reversal of adverse remodelling could be demonstrated in up-to end-stage disease. A further understanding of the underlying cellular, extracellular, molecular and genetic alterations in ischemic remodelling should reveal other promising targets for prevention and reversal of remodelling.