One of the most important health achievements during the 20th century was the unravelling of the causes of vascular diseases (CVDs). Developing the risk factor paradigm helped us to understand the unparalleled rise and fall in CVD mortality rates seen in many Western countries. Despite the substantial decrease in the past 40 years, CVD is still an important burden for societies across the world. Annually in the UK, there are 200 000 deaths from CVD (60 000 premature with health and social costs exceeding 30 billion.1

Dealing with this burden will be challenging. The US healthcare system is already facing economic crisis. Today’s planners require renewed efforts to control this disease. We are very fortunate, because this group of diseases has been extensively studied. We have detailed knowledge of its causation and what effects can come from evidence-based therapeutic interventions.

Since the 1980s, coronary heart disease (CHD) mortality rates have halved in many developed countries and have fallen by 75% in countries like Finland.2 Comparable falls have also been seen in those Mediterranean countries with lower rates, such as France and Italy (fig 1).3 But are these achievements going to persist?

Modern cardiovascular treatments have played an important role. The explosion in evidence-based treatments since the 1980s has provided us with tools to modestly increase life expectancy in those affected by disease. But it is important to recognise that about half of all CVD related deaths occur outside hospitals, usually before any emergency care can be offered. Furthermore, this is often the first manifestation of CVD.4

Treatments will play an important role in any future CVD strategy. However, our increasingly precise understanding of CHD causation suggests that most of the CHD disease burden can be attributed to modifiable lifestyle and dietary risk factors.5^–7

Furthermore, …