<International Circulation>: Cardiovascular disease is common throughout the world. As developed nations increasingly practice early intervention， the morbidity and mortality related to cardiovascular illness is significantly reducing. How are national health care systems globally coping with， and handling changes in populations and knowledge?

    Dr Krumholz:  It is not clear whether governments and health systems around the world are taking a proactive enough view of this. They are often confronting the challenges that exist today and the ones they see existing tomorrow， but as they look towards the next five and ten years， they feel they don’t have the time and resources to do the kind of planning that is necessary to take into account how the underlying population is changing (specifically that most countries are having an increasingly aging population)， and how the marked expansion in knowledge can appropriately be integrated into practice. The attention to the urgent is sometimes at the expense of what needs to be more strategic thinking about long-term planning.

    <International Circulation>: What do you see then are the health care challenges facing developing countries like China?

    Dr Krumholz: China has the challenge of immense demands on its health care system and limited capacity to deliver high quality care to all of its citizens. China has immense talent and a great capacity for technological advances. On every visit to China I am so impressed by the dedication， intelligence and diligence of the Chinese physicians and surgeons. They are avid learners and skilled practitioners. They inspire me by their commitment to deliver the best care. And yet， I realize that in the rural areas there is a very large population that needs care that has relatively less access to some of the advanced technologies， in fact， some areas with no access at all. Creating a system that has the capacity to deliver high quality care in an efficient manner is a challenge for all health care systems - but is one that is particularly challenging for China given resource constraints and the immense needs of the people. Moreover， there are challenges to ensure equitable access to care， ensuring that there are no financial barriers to needed care. And investments in prevention are essential， but like most countries， there are entrenched behaviors that are hard to change and it will take a national commitment and resources to change normative behavior. For example， smoking is so prevalent here among men and there is an imperative to reduce the rate dramatically.

    <International Circulation>:The trend today is towards individualised prevention therapy to tackle cardiovascular disease. What are the contributing factors towards these trends and do they reflect observations and findings from clinical trials and studies?

    Dr Krumholz: This is another area where I think China has a chance to provide substantial leadership. For a long time we have been looking at average results from trials which we incorporate whatever those findings are into our guidelines and recommendations and education and our practice patterns. We are beginning to recognize that embedded within the trial population are responders and non-responders. There are people for whom particular strategies are wonderful and others for whom there is no benefit. Some of that is about biology; some it has to do with system context (what other therapies are they using， and what other care is being provided). We need to learn more about how to best characterize the risks and benefits of particular clinical options for each patient， tailoring the recommendations to the characteristics of each individual. This approach needs to be science-based - not just opinion-based.

    Then there is the whole other aspect to this about patient preference – about how people feel about the treatments that are being suggested to them and how well they will take the suggestions that are being provided by health care practitioners. We need to ensure that we are incorporating the preferences of patients. Sometimes they will prefer strategies that do not have the best risk:benefit balance - but fit their preferences best. As long as they understand the facts， we need to allow them to make the best decision for them. Medicine will reach its apogee when the information is personalized and the decision is patient-centered. I really believe that this will be a role for China because of the number of people here and the way in which it is organized， to potentially provide us with a lot of information which will contribute to us all moving along in this direction.