Abstract Background We assessed the prevalence of risk factors for cardiovascular disease (CVD) in a middle-income country in rapid epidemiological transition and estimated direct costs for treating all individuals at increased cardiovascular risk, i.e. following the so-called "high risk strategy". Methods Survey of risk factors using an age- and sex-stratified random sample of the population of Seychelles aged 25–64 in 2004. Assessment of CVD risk and treatment modalities were in line with international guidelines. Costs are expressed as US$ per capita per year. Results 1255 persons took part in the survey (participation rate of 80.2%). Prevalence of main risk factors was: 39.6% for high blood pressure (≥140/90 mmHg or treatment) of which 59% were under treatment; 24.2% for high cholesterol (≥6.2 mmol/l); 20.8% for low HDL-cholesterol (2) and 22.1% for the metabolic syndrome. Overall, 43% had HBP, high cholesterol or diabetes and substantially increased CVD risk. The cost for medications needed to treat all high-risk individuals amounted to US $45.6, i.e. $11.2 for high blood pressure, $3.8 for diabetes, and $30.6 for dyslipidemia (using generic drugs except for hypercholesterolemia). Cost for minimal follow-up medical care and laboratory tests amounted to $22.6. Conclusion High prevalence of major risk factors was found in a rapidly developing country and costs for treatment needed to reduce risk factors in all high-risk individuals exceeded resources generally available in low or middle income countries. Our findings emphasize the need for affordable cost-effective treatment strategies and the critical importance of population strategies aimed at reducing risk factors in the entire population.