The incidence of cardiovascular disease (CVD) is increasing rapidly in countries with low and middle income. That part of the world accounts for an estimated 80 % of the global CVD burden. Even worse, CVD in less affl uent countries starts to affect people at younger age. Paradoxically, the CVD risk factors in poor countries are less prominent than in high-income countries. This paradox between low incidence of CVD risk on the one hand and increasing CVD mortality on the other was subjected to

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... ritical review of many investigators. In seventeen countries and fi ve continents, they assessed the risk and mortality in more than 156,000 individuals at an average age of fi fty, using the INTERHEART Risk Score. Participants were followed for the incidence of cardiovascular disease and death for a mean of 4.1 years (1). Another INTERHEART study (2) was focused on CVD risk factors. This was a large standardized case-control study involving cases of fi rst myocardial infarction from 52 different countries, compared with their sex-and age-matched controls. Nine modifi able risk factors were found to have a globally consistent association with myocardial infarction, namely apolipoprotein levels, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, adverse dietary factors, insuffi cient physical exercise, and alcohol consumption. After having these CVD risk factors specifi ed, their analysis in 17 countries with low, middle, and high-income revealed (1) that the risk declined from affl uent to impoverished countries both in urban and rural areas. Conversely, the prevalence of major cardiovascular diseases (myocardial infarction, stroke, and heart failure), as well as total mortality proved to have an opposite trend, namely it increased toward poor countries (Figs 1 and 2) . How can this seeming paradox of high CVD risk and low CVD disorders and related mortality be explained? Regarding the risks, wealth promotes consumption of calorically rich diet, physical inactivity, and body overweight with adverse health consequences. Still, populations benefi ting from this horn of plenty live longer and are affl icted with less CVD than their less fortunate contemporaries in countries with less effi cient economy, lower domestic product and more restrictive society. Despite less prominent CVD risks, poor countries have more CVD disorders and mortality associated with shorter life expectancy. A unifying explanation of this paradox between CVD risks and CVD mortality is the benefi t of well-functioning economy and a 0 5 10 15