The study used a validated risk assessment tool to screen a rural population in China for having high risk of CVD. 5.5% of residents aged between 40 to 75 years (2.3% of the total population) were identified as having a CVD risk of 20% or more over within 8 years. The record review and interview found that the majority (76%) of those with a CVD risk of 20% or higher had been diagnosed: over 70% had hypertension, 10% had diabetes and 10% had a cardiovascular disease such as angina. Of those of high CVD risk not being diagnosed with a disease, the majority had elevated blood pressures, fasting blood glucose or lipid profile as compared to the national diagnostic guidelines 
. Thus, they may be likely to be diagnosed as hypertension, diabetes (including pre-diabetes) or hyperlipidaemia after further clinical investigation. In the end, it is likely that over 94% of the high risk population should be diagnosed with CVD or related diseases.
Our findings suggest that this record review and CVD risk assessment strategy is useful in the detection of undiagnosed patients. Indeed, the majority of our undiagnosed high risk population was hypertensive or diabetic patients. The majority of residents who had hypertension or diabetes in this study in rural China were not aware of their diseases and/or not getting proper treatment. A national survey showed a 8.2% diabetes prevalence in rural areas in 2008; however, the rate of diagnosed diabetes was only 2.7% 
. The 2002 national hypertension survey showed that 23% patients with hypertension were aware of it, 17% were on treatment, and 4% had their blood pressure under control 
Using this risk approach has cost-effective implication on the detection and treatment of CVD patients as well. A previous modeling study showed that applying risk assessment tools would result in treating the same number of patients as in the usual care as treating only patients identified with CVD related diseases. However, the risk screening approach, prioritising identification and treatment of those with high CVD risk, should prevent more CVD events and be more cost effective according to estimates in the modeling study 
In this study, we examined the use of highly effective drugs to prevent CVD events based on suggestions from systematic reviews and trials. It was found very few (26%) of the rural residents with high risk CVD were taking any drugs. A survey over 628 communities around the world found that less than one quarter of CVD patients ever took these preventative drugs, while over half of patients in developing countries did not use drugs at all 
. The WHO PREMISE study reported over 70% of CVD patients in developing countries received aspirin, and around 20–40% received anti-hypertensive drugs and/or statins 
. The WHO study was largely based on patients from teaching hospitals, thus resulting in a higher rates of drug intake compared with our study which was community based.
The reasons of low use of the highly effective drugs need further investigation, but are likely to include the limited knowledge of the doctors, belief in traditional therapies, non use of a CVD risk approach, and the cost of preventive drugs. However, these drugs are widely available in rural China at relatively affordable costs. Suppose that one takes the composition of nefidipine 30 mg, hydrochlorothiazide 50 mg, simvastatin 40 mg, aspirin 75 mg and folic acid 5 mg per day from the generic drugs, the total costs of drugs per month is RMB111 (USD17.3) in rural Zhejiang. The majority of the costs are from simvastatin, a statin. Without statin, the combination of two antihypertensives, aspirin and folate only costs as low as RMB6 (nearly US$1) per month. In addition, the rural health insurance in China covers 30% of drugs purchased from township hospitals. Paying the combination with statin may not be affordable, because the cost is much higher than the current RMB17 (USD6.3) per month found in our study, but paying a combination without statin should not be a problem. Another survey in northern China found hypertensive patients over-estimated the effect of drug treatment, and were willing to pay RMB 42 (USD6.6) per month for drug treatment if being informed having a CVD risk of 35% in 5 years 
. Another possible reason is low awareness of the need of lifelong use of the preventative drugs by doctors in rural practice, so the highly effective drugs are simply not prescribed. For those taking drugs, 44% of participants in this study reported missing at least one dose per week, while 19% reported having occasions of stopping treatment for at least a month. Our findings suggest that adherence to drugs could be a challenge in the CVD prevention and treatment, echoing the study elsewhere 
. Adherence support strategies can be learned from tuberculosis control using treatment supporters and reminders 
, though CVD is much challenging because it needs life-long treatment.
The current health reform in China makes a CVD risk reduction strategy feasible. The resident health records can provide the basis to apply risk assessment and identify those with high risk of CVD. Primary care facilities, including township hospitals, village clinics and community health centres, are strengthened with recent government policy investment in public health activities. Chronic disease control has become a responsibility of doctors and nurses at the primary care facilities. Zhejiang provincial government has designated outpatient doctors in township hospitals as “family doctors”. One family doctor is responsible for acute and preventative care, including chronic disease control, for an average population of 1500. Currently in China CVD risk reduction is not generally practiced 
. Based on this, we would suggest a holistic CVD risk reduction approach, which should include screening patients/records, the use of highly effective drugs, adherence support and healthy lifestyle support. This package can be designed to be implemented by primary care health workers in rural China 
The study has several limitations. First, the Asian Equation estimates CVD events in 8 years while most other predictive equations estimate for 10 years. Using a similar cut-off of 20% as high CVD risk, the number of high risk people with CVD identified by the Asian Equation may be lower than that identified using other equations. However, the Asian equation has better predictive value on both ischaemic and hamoerrhagic CVD events compared with other equations in Chinese population. Second, samples are taken from two townships in rural Zhejiang, thus, the results cannot be extrapolated further. Third, information of the resident health records were collected by doctors and nurses from township hospitals. The accuracy may not be complete; however, all doctors and nurses involved in building up the health record were trained based on a provincial guideline, and all diagnosis of CVD, hypertension, diabetes and hyperlipedaemia were checked against their previous medical records. Fourth, a further caution in interpretation is that 67 (15%) of the high risk population did not participate in the survey, though their CVD risk was not different from those who participated in the survey. Furthermore we did not collect information in the survey regarding daily salt intake, exercise or any healthy lifestyle advice given by their doctors or nurses.
By examining the current situation of rural population with high risk of CVD in China, the study found that the majority of the high risk population had already been diagnosed with a CVD related disease. However, only a quarter of these were currently taking any drugs, and less still took highly effective drugs to prevent CVD. We suggest a community-based CVD risk reduction approach, designed to be implementable within the current China public health and rural health insurance reforms, in so doing improve care and reduce CVD events at the primary care level.