Causes of the burgeoning cardiovascular epidemic in developing countries (DC) are known. Whilst there are many prevention strategies and policies demonstrated to be effective in reducing the trends of cardiovascular disease in developed countries, applying them in DCs is challenging and complex. To utilize resources efficiently, two key decisions have to be made by policy makers in all DCs. The first is to decide on the appropriate mix of population and high-risk interventions. The second is to determine the threshold for implementing high-risk interventions. In making such decisions, due consideration needs to be given to scientific evidence, affordability, sustainability, opportunity costs, and social and political realities. High-risk approaches can be made cost-effective if individuals that are most likely to benefit from treatment can be identified through risk stratification systems. Although several such risk prediction systems are available, they have limited applicability to non-Western populations. Further, health systems in DCs do not have basic infrastructure facilities to support resource intensive risk prediction tools, particularly in primary healthcare. The World Health Organization has developed a flexible cardiovascular disease risk management package that is implemented in a range of less resourced settings. A risk prediction tool that enables more accurate prediction of cardiovascular risk in DCs is in development.