This year's Update in Cardiology incorporates the most interesting, innovative, and important articles in the field from 2003, including papers on risk factors for heart disease, new treatment approaches, and issues in chronic heart failure. Despite strides in public education and treatment, cardiovascular disease is still the leading cause of death in the United States. Since 1997, the relative mortality rates from coronary artery disease and stroke have decreased by 4.5% and 1.6%, respectively, and the prevalence of hypercholesterolemia and of smoking has decreased by 14% and 3.8%, respectively. However, in that same period, the national prevalence of hypertension, physical inactivity, diabetes, and obesity has increased by 18%, 5%, 4%, and 8%, respectively. All of these factors fuel the increasing prevalence of the metabolic syndrome and contribute to current and future cardiovascular disease.