Objectives The purpose of this study is to estimate the prevalence of ideal cardiovascular health and its relationship with incident cardiovascular disease (CVD). Background An American Heart Association committee recently set a goal to improve the cardiovascular health of Americans by 20% by 2020. The committee developed definitions of “ideal,” “intermediate,” and “poor” cardiovascular health for adults and children based on 7 CVD risk factors or health behaviors. Methods We used data from the Atherosclerosis Risk in Communities Study cohort, age 45 to 64 years, to estimate the prevalence of ideal cardiovascular health in 1987 to 1989 and the corresponding incidence rates of CVD. Incident CVD comprised stroke, heart failure, myocardial infarction, and fatal coronary disease. Results Among 12,744 participants initially free of CVD, only 0.1% had ideal cardiovascular health, 17.4% had intermediate cardiovascular health, and 82.5% had poor cardiovascular health. CVD incidence rates through 2007 showed a graded relationship with the ideal, intermediate, and poor categories and with the number of ideal health metrics present: rates were one-tenth as high in those with 6 ideal health metrics (3.9 per 1,000 person-years) compared with zero ideal health metrics (37.1 per 1,000 person-years). Conclusions In this community-based sample, few adults in 1987 to 1989 had ideal cardiovascular health by the new American Heart Association definition. Those who had the best levels of cardiovascular health nevertheless experienced relatively few events. Clearly, to achieve the American Heart Association goal of improving cardiovascular health by 20% by 2020, we will need to redouble nationwide primordial prevention efforts at the population and individual levels.