Developed countries have enjoyed substantial falls in cardiovascular disease (CVD) mortality. However, low and middle income countries are drowning in a rising tide of CVD and other non-communicable diseases. Current and future trends in CVD mortality will therefore require increasing attention in the 21st century. The success of clinical cardiology in providing evidence-based cost-effective treatments should be celebrated. However, the growing understanding of CVD mortality trends highlights the crucial role of tobacco, diet, alcohol and inactivity as key drivers. Pro-active public health approaches focused on 'upstream' population-wide policies are increasingly recognised as being potentially powerful, rapid, equitable and cost-saving. However, the future political challenges could be substantial.