At the beginning of the 21st century, the record in the fight against CVD has been mixed. Tremendous gains have been seen in our understanding of the etiology, treatment, and prevention of CVD. There has been modest success in implementing preventive risk-reduction therapies. For instance, the prevalence of smoking has declined, and significant gains have been made in the development and the implementation of effective secondary prevention measures. However, in the face of these successes, disturbing trends have emerged. Obesity and diabetes mellitus are increasing in epidemic proportions, and gains in smoking cessation and physical activity appear to be stagnating. Furthermore, as affluent Americans are receiving increasingly better CV care and enjoying a longer life span free of CVD, the ethnic and economic disparities are widening. In addition, in all economic strata, ethnicities, and regions, the gap between primordial, primary, and secondary CVD prevention goals and the reality of implementation is enormous. Despite the emergence of these new challenges, unprecedented opportunities exist for CVD prevention. Given the breadth and richness of the accumulated knowledge base, society is now in a position to envision the ultimate control of CVD. The fundamental causes of atherosclerosis, hypertension, and diabetes are increasingly understood; highly effective preventive interventions are known; and many therapeutic modalities are available to treat patients with established disease. Based on an examination of the last four decades, when overall CVD death rates in the U.S. have declined an average of 2.5% per year, a future date can be projected when mortality from CVD will be markedly lower assuming that the current rate of decline continues (Table 1). Furthermore, based on accumulated epidemiological experience worldwide, a population lifestyle can be specified that would be associated with very low or absent rates of atherosclerosis. Thus, eliminating smoking, reducing total fat to less than 25% to 30% of calories and saturated fat to less than 7%, reducing dietary salt to less than 3 g/day, eliminating obesity, encouraging moderate daily physical activity, and treating high BP and high cholesterol with available drugs can confidently be predicted to reduce CHD rates to very low levels, perhaps less than 10% to 15% of all deaths. That level of mortality should qualify as an achievable goal over the next 20 years. Achieving a lifestyle that promotes that level of CV health for all members of society remains an enormous practical challenge in political terms, requiring fundamental changes in food production and marketing, community design, work routines, and patterns of care delivery. Nonetheless, attempts should continue to communicate more forcefully the enormous success of the scientific enterprise in its evolution of the position that CVD would now be controlled if existing knowledge were put into practice. The cardiology community thus has a unique obligation to promote CV health, particularly in the medical setting. The cardiology community must partner with others to remove obstacles to disease prevention in the health care environment, including the community, the medical setting, and patients. To achieve significant reductions in CVD will require the following: 1) intensive research into the attitudinal, knowledge, and organizational barriers that decrease adherence to known efficacious preventive strategies; 2) the funding of commitments to research and to the delivery of preventive services; 3) policy changes to guarantee access to care by all members of society, to promote healthy lifestyles and environments in the community, and to facilitate a shift in emphasis toward prevention by health care providers; and 4) changes in clinical practice to emphasize prevention.