Since the publication of the National Service Framework for coronary heart disease, there has been a move towards primary disease prevention with a greater focus on an individual's absolute risk. Meta-analysis and systematic reviews of the evidence for primary prevention are incomplete and the current guidelines and policy have led to considerable confusion in clinical practice. There is an increased use of risk assessment tools but no effective method of reviewing current activity with the limited integration into the existing Quality Outcome Framework. There is an inadequate evidence for some of the risk factors used to identify individuals at risk, the risk calculators used to quantify the degree of risk and the methods of communicating risk to patients are largely unproven or completely missing. There is a need for a co-ordinated vascular disease prevention programme which can be applied at the individual and at the population level but is also amenable to evaluation.