Interpretation of the Report on Cardiovascular Health and Diseases in China 2024

LIU Mingbo, HE Xinye, YANG Xiaohong, WANG Zengwu*

National Center for Cardiovascular Diseases/Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing 100037, China

*Corresponding author: WANG Zengwu, Chief Physician/Professor; E-mail: wangzengwu@foxmail.com

Abstract

Cardiovascular diseases (CVD) and their risk factors are exerting an increasingly significant impact on public health, with CVD incidence continuing to rise. The economic burden on both individuals and society is mounting, making CVD a major public health challenge that urgently requires strengthened government-led prevention and control efforts. This article provides an interpretation of key findings from the newly published Annual Report on Cardiovascular Health and Diseases in China (2024), aiming to offer scientific evidence for CVD prevention, treatment, and policy formulation.

Keywords: cardiovascular diseases; epidemiology; burden of disease; risk factors; prevalence; mortality; rehabilitation; basic research; medical device development; expense

Introduction

With socioeconomic development, lifestyle changes, accelerated population aging, and urbanization, unhealthy lifestyles have become increasingly prevalent among Chinese residents. The impact of CVD risk factors on public health has grown more pronounced, and CVD incidence continues to climb. The resulting economic burden on individuals and society has become substantial, establishing CVD as a critical public health issue that demands urgent government-led prevention and control initiatives. Since 2005, the National Center for Cardiovascular Diseases has annually organized national experts to compile the China Cardiovascular Health and Diseases Report (hereinafter referred to as the "Annual Report"). This year marks the 20th anniversary of the publication. Over the past two decades, as a frontier information source for CVD prevention and treatment, the Annual Report has embodied the diligent efforts of generations of expert reviewers, authors, and publishers, validating the foresight of leading CVD specialists and demonstrating significant value in China's CVD prevention and treatment endeavors. This article interprets the key contents of the newly published China Cardiovascular Health and Diseases Report 2024 [1] to provide scientific evidence for CVD prevention and policy development.

1.1 Epidemiological Status of Cardiovascular Diseases

1.1.1 CVD Incidence

According to Global Burden of Disease (GBD) study data, the total number of CVD cases, crude incidence rate, and age-standardized incidence rate in China increased from 5.3007 million cases, 447.81 per 100,000, and 646.20 per 100,000 in 1990 to 12.3411 million cases, 867.65 per 100,000, and 652.21 per 100,000 in 2019, respectively. The age-standardized incidence of CVD among Chinese residents showed an overall upward trend from 1990 to 2019. Projections for 2020–2030 indicate continued increases in predicted CVD incidence, mortality, and disability-adjusted life year (DALY) rates [2].

From January to December 2023, data from the "China Residents' Cardiovascular and Cerebrovascular Events Surveillance" project, covering 262 surveillance sites in 30 provinces, autonomous regions, municipalities, and the Xinjiang Production and Construction Corps, revealed that the crude incidence of cardiovascular and cerebrovascular diseases (including acute myocardial infarction [AMI], angina undergoing percutaneous transluminal coronary angioplasty [PTCA]/stent implantation and/or coronary artery bypass grafting [CABG], stroke, and sudden cardiac death) among residents aged 18 and above was 620.33 per 100,000 (age-standardized rate: 635.81 per 100,000). The incidence rate was higher in males (crude rate: 717.36 per 100,000; standardized rate: 738.49 per 100,000) than in females (crude rate: 519.64 per 100,000; standardized rate: 530.61 per 100,000) [FIGURE:1]. Cardiovascular and cerebrovascular disease incidence increased rapidly with age [FIGURE:2].

1.1.2 CVD Mortality

In 2021, CVD remained the leading cause of death, surpassing cancer and other diseases [FIGURE:3, 4] [3]. CVD accounted for the highest proportion of deaths in both urban and rural areas, representing 48.98% of major disease deaths in rural areas and 47.35% in urban areas [FIGURE:6, 7]. Rural CVD mortality rates have exceeded urban rates since 2009 [FIGURE:5]. In 2021, the crude CVD mortality rate was 364.16 per 100,000 in rural areas (including 188.58 per 100,000 from heart disease) and 305.39 per 100,000 in urban areas (including 165.37 per 100,000 from heart disease), with higher rates in rural than urban regions. Male coronary heart disease mortality exceeded female mortality in both urban and rural settings.

Data from China's National Mortality Surveillance System (NMSS) [4] showed that the age-standardized mortality rate (ASMR) for CVD decreased from 286.85 per 100,000 in 2005 to 245.39 per 100,000 in 2020, with males having higher ASMR than females in all survey years [FIGURE:8]. The burden of premature CVD death in 2020 decreased by 19.27% compared with 2005. However, premature mortality remains high, and total CVD deaths continue to increase, rising 48.06% from 2015 to 2020, primarily due to population aging and secondarily to population growth. In 2020, ischemic heart disease, cerebral hemorrhage, and cerebral infarction were the three leading causes of CVD death. Among individuals aged 15–50 years, ischemic heart disease accounted for 50%–60% of the CVD premature mortality burden. Substantial regional variations exist in CVD deaths and ASMR, with economically developed areas generally showing lower rates than less developed regions.

1.1.3 Coronary Heart Disease

Prevalence: The "China Residents' Cardiovascular Disease and Risk Factors Surveillance" project surveyed 262 surveillance sites across 31 provinces, autonomous regions, and municipalities from 2020–2022. Preliminary results indicated a coronary heart disease (including AMI, stent implantation, CABG, and hospitalization for unstable angina) prevalence of 758 per 100,000 among residents aged 18 and above, with higher rates in males (940 per 100,000) than females (570 per 100,000) and in urban areas (892 per 100,000) than rural areas (639 per 100,000). Coronary heart disease prevalence increased rapidly with age [FIGURE:9].

Incidence: From January to December 2023, surveillance data from 262 sites in 30 provinces, autonomous regions, municipalities, and Xinjiang showed that the crude incidence of AMI among residents aged 18 and above was 87.6 per 100,000 (age-standardized rate: 93.9 per 100,000), with higher rates in males (113.3 per 100,000) than females (60.9 per 100,000). AMI incidence increased sharply with age [FIGURE:10, 11].

Mortality: According to the China Health Statistics Yearbook 2022 [3], the crude coronary heart disease mortality rate in 2021 was 135.08 per 100,000 in urban areas and 148.19 per 100,000 in rural areas, with male rates exceeding female rates in both settings [FIGURE:12]. Coronary heart disease mortality has continued rising since 2012, with rural areas showing a more pronounced increase and surpassing urban levels by 2016 [FIGURE:13]. AMI mortality showed an overall upward trend from 2002–2021, with a rapid increase beginning in 2005. Rural AMI mortality exceeded urban rates in 2007, 2009, 2010, and 2011, and has been consistently higher since 2013 [FIGURE:14].

1.1.4 Cerebrovascular Disease

Prevalence: GBD 2021 results showed that China had 26.34 million stroke patients in 2021, a 145.4% increase from 1990. Ischemic stroke (IS) showed the largest increase in prevalence (216.3%), followed by cerebral hemorrhage (40.8%) and subarachnoid hemorrhage (19.8%). The age-standardized stroke prevalence rate in 2021 was 1,301.4 per 100,000 (IS: 1,018.8; cerebral hemorrhage: 222.1; subarachnoid hemorrhage: 68.9 per 100,000). Compared with 1990, the age-standardized stroke prevalence increased by 11.5%, with IS increasing by 34.2% while cerebral hemorrhage and subarachnoid hemorrhage decreased by 28.0% and 36.2%, respectively.

Incidence: GBD 2021 data indicated 4.09 million new stroke cases in 2021, a 142.6% increase from 1990. IS showed the largest increase in incidence (264.2%), followed by cerebral hemorrhage (51.6%), while subarachnoid hemorrhage decreased by 3.6%. The age-standardized stroke incidence rate was 204.8 per 100,000 (IS: 135.8; cerebral hemorrhage: 61.8; subarachnoid hemorrhage: 7.8 per 100,000). Compared with 1990, the age-standardized stroke incidence decreased by 9.8%, with cerebral hemorrhage and subarachnoid hemorrhage declining by 43.9% and 56.5%, respectively, while IS increased by 35.7%.

From January–December 2023, surveillance data showed a stroke incidence of 491.0 per 100,000 (age-standardized rate: 513.3 per 100,000) among residents aged 18 and above, with higher rates in males (551.8 per 100,000) than females (427.9 per 100,000). Stroke incidence increased with age [FIGURE:15, 16].

Mortality: In 2021, cerebrovascular disease mortality was 140.02 per 100,000 in urban areas (21.71% of total urban deaths, ranking third among all causes) and 175.58 per 100,000 in rural areas (23.62% of total rural deaths, ranking second). Mortality was higher in males than females and in rural than urban areas [FIGURE:17]. Both urban and rural cerebrovascular disease mortality rates increased with age, with male rates exceeding female rates in all age groups, showing an approximately exponential trend [FIGURE:18, 19].

1.2 Smoking

China's adult smoking rate decreased from 28.1% in 2010 to 24.1% in 2022, a 14.2% relative decline over 12 years [5]. Regional adult tobacco surveys showed that Shanghai and Tibet achieved smoking rates below 20.0% in 2020, while Yunnan and Guizhou exceeded 30.0%. Eighteen provinces fell within 20.0%–24.9%, and nine provinces within 25.0%–29.9% [6].

In 2023, the smoking rate among middle school students was 4.2%, unchanged from 2021, with an estimated 3.76 million middle school students smoking nationwide. The trial smoking rate among middle school students was 13.7% in 2023, a critical indicator for initiating regular smoking. Frequent smoking (≥20 days/month) was 1.2%, and daily smoking was 0.8%. Male students showed significantly higher rates than female students across all smoking measures (trial smoking: 19.1% vs 7.8%; current smoking: 6.4% vs 1.8%; frequent smoking: 2.0% vs 0.3%; daily smoking: 1.4% vs 0.2%). Vocational high schools had the highest smoking rates (22.3% trial, 9.6% current, 3.6% frequent, 2.6% daily), followed by regular high schools and middle schools. In 2023, 54.5% of middle school students reported secondhand smoke exposure, most commonly in outdoor public places (40.2%), indoor public places (37.5%), homes (29.4%), and public transportation (20.2%). Notably, 35.4% reported exposure at school in the past 30 days, with 8.3% witnessing teachers smoking at school almost daily [7].

1.3 Diet and Nutrition

National nutrition survey data from 1982 to 2015–2017 [8-9] show that Chinese residents' food intake patterns have changed significantly [FIGURE:20]. Grain and vegetable consumption has decreased, along with reduced whole grain and tuber intake. The animal food structure remains suboptimal, with excessive intake of livestock meat (especially pork) and insufficient poultry and aquatic products. Fruit, egg, dairy, and soybean intake remains persistently low compared with recommendations. Cooking oil intake continues to increase, and although household cooking salt has decreased, intake levels in 2015–2017 (cooking oil: 43.2 g/day; salt: 9.3 g/day) far exceed recommendations.

The China Nutrition and Chronic Disease Report (2020) [8] indicated adequate total energy supply, with average daily intake of 2,007.4 kcal per standard person, showing a declining long-term trend. Carbohydrate energy contribution has decreased significantly, while fat energy contribution has risen continuously, exceeding the recommended upper limit of 30% in urban residents since 2002 and reaching 33.2% in rural residents in 2015–2017 [8-10]. Data from the China Health and Nutrition Survey (CHNS) and 2022–2023 China Development and Nutrition Health Impact Cohort Survey in 10 provinces [11] showed that compared with 2018, adult energy intake slightly decreased in 2022–2023, while fat energy contribution further increased to 40.08%, carbohydrate contribution decreased to 44.06%, and protein contribution remained stable at 13.02%. In 2020, Chinese children aged 6–17 years had a fat energy contribution of 33.7% [12].

1.4 Physical Activity

In 2020, 62.3% of children aged 3–6 years met moderate-to-vigorous physical activity guidelines, with higher rates in urban (63.1%) than rural (58.6%) areas, while screen time compliance was 52.8% [13]. Among primary and secondary school students in 2016, 85.2% had ≥2 physical education classes per week and 31.5% had ≥5 extracurricular sports sessions per week, while 23.7%, 27.7%, and 17.5% spent ≥2 hours on weekends watching TV, using mobile phones, or using computers, respectively [14]. Activity compliance rates among primary and middle school students were higher in 2017 than in 2016 [15-16], but declined significantly from 2017–2019 (primary: 32.61% to 25.33%; middle school: 28.15% to 17.61%), while screen time compliance (<2 hours) among primary students also declined significantly (86.47% to 80.55%) [17]. In 2019, 39.3% of individuals engaged in muscle-strengthening exercise ≥3 times per week [18].

1.5 Overweight and Obesity

Multiple surveys including the China Nutrition and Health Surveillance (CNHS), China Chronic Disease and Risk Factor Surveillance (CCDRFS), CHNS, and national student physical fitness surveys consistently show a continuous upward trend in overweight and obesity rates across different genders, ages, and regions, with faster growth in rural than urban areas [8-9, 20-21]. The "13th Five-Year National Science and Technology Basic Resources Survey Special Project—China 0–18 Years Child Nutrition and Health Systematic Survey and Application" examined 105,000 children aged 0–18 years across seven regions [12]. In 2020, the overweight and obesity rate was 7.8% among children aged 0–5 years (overweight: 5.7%; obesity: 2.1%), higher in rural than urban areas and in boys than girls. Among children and adolescents aged 6–17 years, the rate was 26.5% (overweight: 14.5%; obesity: 12.0%), higher in urban than rural areas and in boys than girls.

The China Nutrition and Chronic Disease Status Report (2020) [8] showed that among Chinese adults aged 18 and above, the overweight rate was 34.3% and obesity rate was 16.4%, representing increases of 4.2 and 4.5 percentage points, respectively, compared with 2012. The "China Residents' Cardiovascular Disease and Risk Factors Surveillance" project (2020–2022) surveyed 293,022 adults across 262 surveillance sites, finding overweight, obesity, and central obesity rates of 34.6%, 17.8%, and 34.9%, respectively. The obesity rate was higher in males (20.5%) than females (15.0%) and in rural (18.7%) than urban (16.7%) areas. Both overweight and obesity rates initially increased then decreased with age [FIGURE:21].

1.6 Hypertension

Nationwide hypertension prevalence surveys from 1958–2022 show an overall upward trend. The "China Residents' Cardiovascular Disease and Risk Factors Surveillance" project (2020–2022) surveyed 298,438 adults across 262 surveillance sites, revealing a hypertension prevalence of 31.6% among those aged 18 and above, higher in males (36.8%) than females (26.3%) and in rural (33.7%) than urban (29.1%) areas. Hypertension prevalence increased rapidly with age.

A prospective cohort study of 12,952 Chinese adults aged 18 and above in the CHNS [22] showed that the age-standardized hypertension incidence rate increased from 40.8 per 1,000 person-years in 1993–1997 to 48.6 per 1,000 person-years in 2011–2015.

Multiple national surveys demonstrate increasing trends in hypertension awareness, treatment, and control rates. CCDRFS data from six national surveys [23] showed rising awareness, treatment, and control rates among adults aged 18–69 from 2004–2018 [FIGURE:22]. The 2020–2022 surveillance project found awareness, treatment, and control rates of 43.3%, 38.7%, and 12.9%, respectively, among adults aged 18 and above.

1.7 Dyslipidemia

The "China Residents' Cardiovascular Disease and Risk Factors Surveillance" project (2020–2022) examined 275,961 adults across 262 surveillance sites, finding mean levels of total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) of 185.8 mg/dl, 141.0 mg/dl, 50.7 mg/dl, and 110.7 mg/dl, respectively. TG levels were higher in males than females [FIGURE:23].

Defining dyslipidemia as any abnormal lipid level (TC ≥ 551.71 mg/dl, LDL-C ≥ 160.22 mg/dl, HDL-C < 40.25 mg/dl, TG ≥ 87.46 mg/dl) or current lipid-lowering medication use, surveys including CHNS 2002 [24], CNSCKD 2010 [25], CHNS 2011 [26], and the 2012 China Nutrition and Chronic Disease Survey [27] showed sharply increasing dyslipidemia prevalence among adults aged ≥18 years. The China Hypertension Survey (CHS) 2012–2015 [28] and ChinaHEART 2014–2019 [29] reported similar prevalence rates among adults aged ≥35 years [FIGURE:24].

The 2020–2022 surveillance project found a dyslipidemia prevalence of 38.1% among adults aged 18 and above, higher in males (46.1%) than females (29.6%) and in urban (38.9%) than rural (37.4%) areas. Prevalence initially increased then decreased with age [FIGURE:25].

1.8 Diabetes

The "China Chronic Disease and Risk Factors Survey" conducted cross-sectional studies of 170,287 and 173,642 adults aged ≥18 years in 2013–2014 and 2018–2019, respectively [30]. Using ADA diagnostic criteria, diabetes prevalence increased from 10.9% (95%CI: 10.4%–11.5%) in 2013 to 12.4% (95%CI: 11.8%–13.0%) in 2018. Prediabetes prevalence rose from 35.7% (95%CI: 34.2%–37.3%) to 38.1% (95%CI: 36.4%–39.7%). In 2018, diabetes awareness, treatment, and control rates were 36.7% (95%CI: 34.7%–38.6%), 32.9% (95%CI: 30.9%–34.8%), and 50.1% (95%CI: 47.5%–52.6%), respectively, with control rates showing little change since 2013. Diabetes and prediabetes prevalence increased significantly in rural areas from 2013–2018.

1.9 Chronic Kidney Disease (CKD)

With economic development and social changes, both CKD prevalence and its etiological spectrum have shifted in China. Preventable and treatable CKD caused by diabetes, hypertension, and urinary obstruction has become dominant. In 2011, diabetic kidney disease surpassed chronic glomerulonephritis as the leading cause of CKD among hospitalized patients in tertiary hospitals [31]. According to the China Kidney Disease Network (CK-NET) annual report, diabetic nephropathy, hypertensive nephropathy, and obstructive nephropathy accounted for 26.7%, 21.4%, and 16.0% of CKD cases among tertiary hospital inpatients in 2016, respectively, all exceeding chronic glomerulonephritis (14.4%) [32].

The "National Sixth Survey on Chronic Diseases and Risk Factors" (August 2018–June 2019) [33] examined 176,874 adults across 31 provinces, finding albuminuria prevalence of 6.7%, renal function impairment of 2.2%, and total CKD prevalence of 8.2%, lower than the 10.8% reported in 2009–2010 [34]. CKD prevalence was higher among older individuals, females, ethnic minorities, rural residents, those living in northern or central China, those with lower education or income, former smokers, non-drinkers, those with insufficient physical activity, and those with obesity, hypertension, diabetes, dyslipidemia, or self-reported CVD.

The "Cardiovascular Disease High-Risk Population Early Screening and Comprehensive Intervention Project" (2015–2019) screened morning urine albumin-to-creatinine ratio (UACR) in 269,026 adults aged ≥35 years across 31 provinces, finding albuminuria (UACR ≥30 mg/g) prevalence of 8.75% (7.38% with 30–300 mg/g; 1.37% with ≥300 mg/g). Prevalence increased with age, lower income and education, and was higher in females (age-standardized: 8.33% vs 7.27% in males) and rural residents. It was also higher among those with hypertension, diabetes, hyperlipidemia, BMI ≥24 kg/m² or <18.5 kg/m², and lower among those with healthy diets and adequate activity. Regional differences were observed, with the highest age- and sex-standardized prevalence in central China [9.35% (95%CI: 9.01%–9.71%)], followed by southwest [8.95% (95%CI: 8.69%–9.23%)] and east China [8.16% (95%CI: 7.95%–8.38%)], and the lowest in south China [5.98% (95%CI: 5.67%–6.30%)].

1.10 Sleep Quality

A 2024 meta-analysis of 32 sleep studies including over 370,000 Chinese individuals, using the Pittsburgh Sleep Quality Index (PSQI) with a cutoff score of 7, found poor sleep quality prevalence of 19.0% (95%CI: 15.8%–22.8%). Populations with lower education levels (Q=4.12, P=0.042) and those living in less developed regions (Q=60.28, P<0.001) were more affected. The PSQI assesses seven dimensions: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction, with total scores ranging 0–21 (higher scores indicating worse sleep quality) [35].

In children, a study using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scale examined emotional states in over 30,000 primary and middle school students before and after the "Double Reduction" policy implementation. Post-policy implementation saw depression symptom prevalence decrease from 12.1% to 9.2% and anxiety symptoms from 8.9% to 6.2% [36].

1.11 Environmental Factors

GBD studies identify air pollution and non-optimal temperature as the top two environmental factors affecting population health in China. Non-optimal temperature ranked 8th among disease burden risk factors in both 2013 and 2021, with over 400,000 excess CVD deaths attributed to non-optimal temperature in 2021. Air pollution dropped from 1st in 2013 to 3rd in 2021, with excess deaths declining but remaining high at 1.467 million, including 1.21 million CVD deaths related to ambient particulate matter pollution. While China has achieved some air quality improvements in recent years, the health impact remains significant.

The China Ecological Environment Status Bulletin reported that in 2023, 203 of 339 prefecture-level cities met outdoor air quality standards (59.9% compliance rate). All six major air pollutants (PM2.5, PM10, SO2, NO2, CO, O3) decreased compared with 2022 [FIGURE:26]. PM2.5 remained the primary pollutant on 40.1% of超标days. The national average PM2.5 concentration was 30 μg/m³ (range: 5–54 μg/m³), a 3.4% increase from 2022. Satellite remote sensing assessment of high-resolution (1 km×1 km) outdoor PM2.5 concentrations from 2000–2016 showed the most severe pollution in the Beijing-Tianjin-Hebei region [37].

2.1 Hypertension

HQMS data showed that in 2023, 6,748 hospitals (83.1% of CVD-treating hospitals) admitted hypertension inpatients (aged ≥18 years with hypertension as primary or other diagnosis), including 2,286 tertiary and 4,462 secondary hospitals. These hospitals admitted 50.37 million hypertension inpatients (65.8% of all CVD inpatients), with 1.85 million having hypertension as the primary discharge diagnosis (mean age: 58.6±16.7 years; 54.5% female) and the remainder having hypertension as a secondary diagnosis (mean age: 66.8±12.5 years; 47.2% female) [FIGURE:27]. The top three comorbidities were coronary heart disease (30.6%), cerebrovascular disease (30.5%), and diabetes (25.8%) [FIGURE:28]. Secondary hypertension accounted for 994,000 cases (2.0% of hypertension inpatients), with renal parenchymal hypertension (41.3%), obstructive sleep apnea syndrome (28.8%), and renovascular hypertension (11.0%) as the leading causes. The inpatient mortality rate for primary hypertension diagnoses was 0.1%, with a non-recovery discharge rate of 3.8%.

2.2 Coronary Heart Disease

HQMS data indicated that in 2023, 6,581 hospitals (81.1% of CVD-treating hospitals) admitted coronary heart disease inpatients (aged ≥18 years), including 2,169 tertiary and 4,412 secondary hospitals. These facilities admitted 8.368 million coronary heart disease inpatients, with tertiary hospitals accounting for 5.677 million and secondary hospitals for 2.691 million. The mean patient age was 66.5 years, with females comprising 43.0%; 77.8% were aged 55–84 years and 16.7% were <55 years [FIGURE:29]. Comorbidities included hypertension (61.3%) and type 2 diabetes (27.5%). The primary discharge diagnoses were unstable angina (40.0%), unclassified coronary heart disease (29.0%), and stable angina (15.1%) [FIGURE:30].

In 2023, 1.222 million AMI inpatients were admitted, including 46.7% with ST-elevation myocardial infarction (STEMI) and 43.1% with non-ST-elevation myocardial infarction (NSTEMI). The inpatient mortality rate for AMI was 4.0% (males: 3.3%; females: 5.5%), with a non-recovery discharge rate of 12.8% (males: 11.6%; females: 15.9%).

Coronary interventions included 1.901 million percutaneous coronary interventions (22.7% of coronary inpatients) and 2.029 million diagnostic angiographies (24.2%). Patients undergoing intervention had a mean age of 63.3 years (28.6% female), with 78.7% aged 45–74 years and 15.6% ≥75 years. PCI accounted for 68.8% of interventions, while PTCA represented 5.7% [FIGURE:31].

In 2023, 654 hospitals performed at least one CABG, with 61,000 isolated CABG procedures performed. The top three provinces accounted for 52% of all CABG surgeries. The ratio of coronary interventions to CABG was 31.4:1 nationally [FIGURE:32]. CABG patients had a mean age of 62.2±8.9 years, with 75.3% aged 55–74 years and 8.0% ≥75 years.

2.3 Arrhythmia

HQMS data showed that in 2023, 7,583 hospitals (93.4% of CVD-treating hospitals) provided arrhythmia care, including 2,485 tertiary and 5,098 secondary hospitals. These facilities admitted 11.132 million arrhythmia inpatients, with the top three diagnoses being atrial tachycardia/atrial flutter/atrial fibrillation (37.84%), atrial premature contractions (18.11%), and ventricular premature contractions (17.10%) [FIGURE:33]. Atrial arrhythmias accounted for 55.9% of cases, reflecting population aging.

Approximately 342,000 arrhythmia ablation procedures were performed (3.1% of arrhythmia inpatients), including 190,000 left atrial appendage closures and 166,000 device implantations (100,000 dual-chamber pacemakers, 21,000 single-chamber pacemakers, 10,000 ICDs, 5,755 CRT-Ds, and 3,727 CRTs) [FIGURE:34]. Conventional pacemakers accounted for over three-quarters of devices. The "ablation plus closure" one-stop procedure showed the highest inpatient mortality, non-recovery discharge, and 30-day readmission rates, followed by left atrial appendage closure, while catheter ablation had the lowest rates. Device implantation maintained low mortality and readmission rates. Among 220,000 syncope hospitalizations, 49.9% had unclear etiology, with vasovagal syncope accounting for only 20%, indicating need for improved clinical diagnosis and coding.

2.4 Valvular Heart Disease

HQMS data indicated that in 2023, 6,794 hospitals (83.7% of CVD-treating hospitals) admitted valvular heart disease patients, including 2,402 tertiary and 4,392 secondary hospitals. These facilities admitted 2.661 million valvular heart disease inpatients, with left atrioventricular (mitral) valve disease being most common (1.339 million, 50.3%), followed by aortic, right atrioventricular (tricuspid), and pulmonary valve diseases [FIGURE:35].

Aortic Valve: In 2023, 9,928 isolated surgical aortic valve replacement (SAVR) procedures were performed, with bioprosthetic valve use at 46.8% (more common in elderly patients). Transcatheter aortic valve replacement (TAVR) was performed in 9,629 cases, approaching SAVR volume [FIGURE:36], with females comprising 41.5% of TAVR patients.

Mitral Valve: In 2023, 28,000 isolated mitral valve surgeries were performed (32.4% repair, 67.6% replacement). The repair proportion decreased with age (78.0% in patients <18 years; 38.9% in >85 years), while replacement increased. Bioprosthetic valve use in mitral replacement was 45.6%, with mechanical valve use decreasing with age (92.8% in <18 years; ~0% in >85 years). In 2023, 3,019 mitral valve interventions were performed, with mitral valve clipping accounting for 49.7% [FIGURE:37].

Pulmonary Valve: In 2023, 1,307 pulmonary valve surgeries were performed (53.1% in patients <18 years; 44.9% male), with a non-recovery discharge rate of 2.4%, significantly lower than in 2022.

Tricuspid Valve: In 2023, 45,000 tricuspid valve surgeries were performed, mostly combined procedures, with 77.6% of patients >45 years and 45.4% male. The non-recovery discharge rate was 3.1%, significantly lower than in 2022. Additionally, 165 tricuspid valve interventions were performed (62.4% female), with inpatient mortality and non-recovery discharge rates of 0.6% each.

2.5 Heart Failure

HQMS data showed that in 2023, 7,374 hospitals (90.8% of CVD-treating hospitals) admitted heart failure inpatients (aged ≥18 years), including 2,415 tertiary and 4,959 secondary hospitals. These facilities admitted 14.29 million heart failure inpatients, with tertiary hospitals accounting for 59.2% and secondary hospitals for 40.8%. Admission routes included emergency (27.9%), outpatient (69.2%), and other pathways (2.9%). The mean age was 71.2±12.6 years, with females comprising 45.3% [FIGURE:38].

Comorbidities included coronary heart disease (68.7%), hypertension (58.9%), atrial fibrillation/flutter (19.8%), cardiomyopathy (2.9%), cardiogenic shock (1.1%), stroke (40.5%), COPD (28.2%), and diabetes (27.0%). The non-recovery discharge rate was 10.2% (inpatient mortality: 2.6%; non-medical discharge: 7.6%), with an 11.0% 30-day readmission rate.

Left ventricular assist devices (LVAD) have significantly improved survival and quality of life for advanced heart failure patients. Since the first long-term LVAD implantation in June 2017, 908 procedures have been performed in 132 hospitals through May 2024 [FIGURE:39]. Outcomes included transition to heart transplant (27 cases, 3.0%), device removal due to cardiac recovery (19 cases, 2.1%), and 133 deaths during long-term follow-up. The longest device support duration was 26.9 years, with a mean support time of 1.02 years. By June 2024, Fuwai Hospital had performed 140 long-term LVAD implantations using three devices: 21 EVAHEART, 75 CH-VAD (China's first fully magnetically levitated LVAD), and 44 CorHeart 6.

Heart transplantation remains the most effective and recognized treatment for end-stage cardiomyopathy. According to the China Heart Transplant Registry, 5,208 heart transplants were performed and reported by mainland China transplant centers from 2015–2023 [FIGURE:40].

2.6 Congenital Heart Disease

HQMS data indicated that in 2023, 4,239 hospitals (52.9% of CVD-treating hospitals) admitted congenital heart disease patients, including 1,974 tertiary (77.4% of all tertiary hospitals) and 2,265 secondary (40.7% of all secondary hospitals) hospitals. These facilities admitted 2.024 million inpatients with congenital heart disease diagnoses, including 339,000 with primary diagnoses. Among primary diagnoses, atrial septal defect (41.71%), ventricular septal defect (9.72%), patent ductus arteriosus (4.64%), coarctation of the aorta (1.01%), endocardial cushion defect (0.66%), and tetralogy of Fallot (0.86%) were most common. Among all congenital heart disease inpatients, 5.82% were neonates/infants (<1 year), 19.76% were children aged 1–18 years, and 74.42% were adults (≥18 years).

In 2023, 177,000 congenital heart disease patients underwent surgical or interventional treatment (47.3% of diagnosed inpatients), including 160,000 simple and 17,000 complex cases. Surgical treatment was performed in 61,000 cases (34.2% of treated patients), with complex cases accounting for 26.8% of surgical patients. Among surgically treated patients, children aged 1–17 years were most common (45.42%), followed by adults (33.53%), with 1,378 neonatal surgeries performed [FIGURE:41].

Adult congenital heart disease surgery (≥18 years, excluding mitral/aortic valve procedures) totaled 20,000 cases, with atrial septal defect repair comprising 49.86%. Surgical mortality was 0.7% and non-recovery discharge rate was 1.7% (simple: 0.3% mortality, 0.8% non-recovery; complex: 2.2% mortality, 3.9% non-recovery).

Interventional treatment was performed in 117,000 cases, with patent foramen ovale closure being most common (47.2%), followed by atrial septal defect, patent ductus arteriosus, ventricular septal defect, and pulmonary valve stenosis interventions [FIGURE:42]. Among children undergoing intervention, atrial septal defect closure was most common (42.9%), while among adults, patent foramen ovale closure predominated (59.4%). Interventional treatment mortality was 0.01% overall (children: 0.01%; adults: 0.01%), with non-recovery discharge rates of 0.44% (children: 0.67%; adults: 0.35%).

2.7 Aortic and Peripheral Vascular Disease

Aortic Disease: In 2023, 4,400 hospitals (50.2% of CVD-treating hospitals) provided aortic disease care, admitting 155,400 inpatients aged ≥18 years. Aortic dissection accounted for 47.4% and aortic aneurysm for 24.7% of cases [FIGURE:43].

Aortic dissection care was provided by 3,926 hospitals (48.4%), admitting 74,000 inpatients in 2023, with 58.6% admitted through emergency departments. The mean age was 58.5±13.8 years (24.2% female), and 77.3% had comorbid hypertension. Surgical treatment was performed in 18.5% of patients, while 47.0% received no surgery. Inpatient mortality was 4.5%, with a non-recovery discharge rate of 17.4%.

Aortic aneurysm care was provided by 2,606 hospitals (32.1%), admitting 41,000 inpatients, with 22.3% admitted emergently. The mean age was 67.5±11.8 years (20.3% female). Hypertension was present in 62.0% of patients. Endovascular surgery was performed in 48.9%, open surgery in 13.8%, and 37.3% received no surgery. Inpatient mortality was 0.5% overall (0.6% for surgical patients), with non-recovery discharge rates of 6.9% overall (2.0% for surgical patients).

Peripheral Vascular Disease: In 2023, 4,077 hospitals (50.2%) provided care for carotid atherosclerotic stenosis/occlusion, and 5,426 hospitals (66.8%) treated varicose veins. These facilities admitted 224,000 carotid stenosis/occlusion inpatients (mean age: 67.2±10.2 years; 29.6% female) and 381,000 varicose vein inpatients. Postoperative mortality for carotid surgery was 0.5%, with a non-recovery discharge rate of 3.0%.

2.8 Pulmonary Vascular Disease

Pulmonary Hypertension: In 2023, 6,238 hospitals admitted 1.638 million adult pulmonary hypertension inpatients (aged ≥18 years), including 2,312 tertiary and 3,926 secondary hospitals. Emergency admissions accounted for 27.1% and outpatient admissions for 70.6%. The mean age was 67.5±18.7 years (49.1% female). Distribution by clinical classification was: Group 1 (7.1%), Group 2 (32.0%), Group 3 (24.2%), Group 4 (1.8%), and Group 5 (4.5%) [FIGURE:44]. Group 1 patients were youngest with highest female proportion, while Groups 2 and 3 were predominantly elderly, and Group 3 was more common in males. Inpatient mortality was 1.6%, with a non-recovery discharge rate of 9.6%.

Venous Thromboembolism: In 2023, 5,632 hospitals admitted 337,000 pulmonary embolism inpatients (0.4% of CVD inpatients), and 6,766 hospitals admitted 1.868 million deep vein thrombosis inpatients (2.2% of CVD inpatients). Among pulmonary embolism patients, 32.1% were admitted emergently, 65.8% through outpatient departments, 56.3% had recent surgery, 35.8% had deep vein thrombosis, and 23.3% had malignancy. Inpatient mortality was 5.7% for pulmonary embolism and 2.3% for deep vein thrombosis, with non-recovery discharge rates of 15.5% and 10.3%, respectively.

2.9 Cardiomyopathy

In 2023, 6,411 hospitals (79.0% of CVD-treating hospitals) admitted 849,000 cardiomyopathy inpatients, including 197,000 with primary diagnoses. Dilated cardiomyopathy accounted for 62.0% and hypertrophic cardiomyopathy for 24.2% of cases [FIGURE:45]. Overall, 37.2% of cardiomyopathy inpatients were female, with variations by type: dilated (36.2% female), hypertrophic (39.9%), restrictive (45.1%), arrhythmogenic (40.6%), and unclassified (40.6%). Inpatient mortality was 0.9%, with a non-recovery discharge rate of 6.2%.

2.10 Cardiac Rehabilitation

HQMS data showed that in 2023, 3.503 million individuals were identified as post-coronary intervention (through procedure codes or diagnosis), with 366,000 (10.5%) receiving cardiac rehabilitation.

2.11 Obstructive Sleep Apnea

In 2023, 4,995 hospitals (61.5% of CVD-treating hospitals) provided obstructive sleep apnea services, including 1,302 (16.0%) offering overnight sleep breathing monitoring and 2,257 (27.8%) providing non-invasive positive pressure ventilation. These facilities admitted 363,000 CVD inpatients aged ≥18 years with comorbid obstructive sleep apnea (0.5% of CVD inpatients), with 8.1% having it as the primary diagnosis and 91.9% as a secondary diagnosis. The mean age was 56.9±14.8 years (27.1% female), with highest representation in the 55–64 age group (24.9%). Top comorbidities were hypertension (78.6%), coronary heart disease (34.0%), heart failure (19.8%), and arrhythmia (19.7%) [FIGURE:46].

2.12 Kidney Disease in CVD Patients

In 2023, 7,471, 5,951, 4,063, 1,840, and 3,388 hospitals (92.0%, 73.3%, 50.0%, 22.7%, and 41.7% of CVD-treating hospitals, respectively) could manage CVD (excluding cerebrovascular disease) with CKD, CVD with acute kidney injury (AKI), and provide hemodialysis, peritoneal dialysis, and continuous renal replacement therapy (CRRT). Among 82.74 million CVD inpatients in 2023, 9.866 million had CKD, 492,000 had AKI, 1.134 million received hemodialysis, 221,000 received peritoneal dialysis, and 280,000 received CRRT [FIGURE:47]. CKD prevalence was 13.3% in males and 10.3% in females; AKI prevalence was 0.7% and 0.5%, respectively. CKD patients had higher inpatient mortality (2.4% vs 0.7%), non-recovery discharge rates (10.3% vs 5.8%), and AKI incidence (1.4% vs 0.6%) than non-CKD patients. AKI patients had higher mortality (14.7% vs 0.8%), non-recovery discharge rates (35.0% vs 6.2%), and renal replacement therapy rates (17.2% vs 2.1%) than non-AKI patients.

2.13 Stroke

In 2023, 7,640 hospitals (including 2,466 tertiary and 5,174 secondary) admitted 16.638 million stroke inpatients, with cerebral infarction accounting for 94.0%. Stroke was the primary diagnosis in 49.9% of cases. Mean ages were 68.9±11.7 years overall, 69.3±11.3 years for cerebral infarction, 62.9±14.3 years for cerebral hemorrhage, and 60.9±15.4 years for subarachnoid hemorrhage [FIGURE:48]. Cerebral infarction and hemorrhage were more common in males (55.0% and 63.5%, respectively), while subarachnoid hemorrhage was slightly more common in females (51.2%). Hypertension (66.5%), coronary heart disease (30.3%), and diabetes (27.7%) were the most common comorbidities. Inpatient mortality was 1.2%, with a non-recovery discharge rate of 8.0%.

In 2023, 6,994 hospitals (90.1% of heart disease-treating hospitals) managed 24.567 million coronary heart disease inpatients, of whom 21.1% had comorbid cerebrovascular disease. Among 4.803 million atrial fibrillation/flutter patients, 21.4% had cerebrovascular disease, as did 6.5% of 1.93 million PCI patients and 10.7% of 74,000 CABG patients. Patients with comorbid cerebrovascular disease had higher inpatient mortality and non-recovery discharge rates.

3.1 CVD Basic Research

High-quality CVD basic research in mainland China began around 2005, with increasing publications in prestigious journals such as Nature, Cell, Circulation, European Heart Journal, Circulation Research, Signal Transduction and Targeted Therapy, Nature Communications, Advanced Science, and Cardiovascular Research. Both the quantity and quality of publications have increased substantially in recent years, with research focusing on myocardial infarction, heart failure, ischemia-reperfusion injury, arrhythmia, cardiomyopathy (hypertrophic, dilated, diabetic, viral), cardiac remodeling (hypertrophy and fibrosis), aneurysm, atherosclerosis, hypertension, vascular aging, and vascular remodeling. Cardiac protection, regeneration, and gene therapy are particularly active research areas. High-quality publications are concentrated in economically developed regions (East China: Shanghai, Zhejiang, Jiangsu; North China: Beijing, Tianjin; South China: Guangdong), demonstrating close correlation between CVD research and economic development.

3.2 CVD Clinical Research

CVD research in China has flourished in recent years, with both quantity and quality improving. China ranks second globally in CVD publications, behind only the United States, with growth rates exceeding those of the US since 2018. The most active subspecialties are coronary heart disease, hypertension, arrhythmia, and heart failure, with coronary heart disease and hypertension publications surpassing US output. In 2023–2024, 20 high-quality clinical research papers were published, covering coronary heart disease, hypertension, arrhythmia, heart failure, congenital heart disease, cardiomyopathy, and CVD risk factors, with particular focus on coronary heart disease, hypertension, and risk factor exploration and intervention.

3.3 CVD Device Research

From July 20, 2023, to July 31, 2024, the National Medical Products Administration approved 74 devices for innovative medical device review, including 36 cardiovascular products (48.6%), with 72 domestic original products (97.3%), demonstrating cardiovascular innovation's dominant position. Eleven devices entered priority review, including one cardiovascular product. No Class III cardiovascular devices required clinical trial approval, indicating lowered barriers. During this period, 206 cardiovascular Class III devices received registration approval, including 178 domestic products (two previously entered the national innovation review channel).

Regionally, the Yangtze River Delta, Pearl River Delta, and Beijing remain industrial clusters, accounting for nearly 80% of all approvals, with the Yangtze River Delta alone representing nearly 50% of the national total.

4.1 CVD Economic Burden

In 2022, China had 26.3387 million cardio-cerebrovascular disease discharges, accounting for 14.73% of all hospital discharges, including 14.252 million CVD cases (54.1%) and 12.087 million cerebrovascular disease cases (45.9%) [FIGURE:49]. Ischemic heart disease (8.764 million, including 4.177 million angina and 1.460 million AMI) and cerebral infarction (8.253 million) predominated, accounting for 33.27% and 31.33% of cases, respectively. Other conditions included hypertension (1.741 million, including 237,000 hypertensive heart/kidney disease), heart failure (2.511 million), cerebral hemorrhage (1.385 million), arrhythmia (985,400), pulmonary embolism (133,800), chronic rheumatic heart disease (106,800), and acute rheumatic fever (10,100) [FIGURE:50].

From 1980–2022, the average annual growth rate of diabetes discharges was 12.34%, cerebral infarction 11.00%, ischemic heart disease 10.16%, cerebral hemorrhage 7.99%, hypertension 5.54%, hypertensive heart/kidney disease 4.84%, and chronic rheumatic heart disease -0.87%. From 1987–2022, AMI discharges grew 10.98% annually; from 2018–2022, heart failure discharges grew 21.41%, angina 14.33%, pulmonary embolism 9.07%, arrhythmia -1.90%, and acute rheumatic fever -13.05%.

HQMS 2023 data showed that among patients with primary CVD diagnoses, coronary heart disease accounted for the highest hospitalization volume and total costs. Within coronary heart disease, unstable angina predominated (40.0% of cases, 334.4 million cases), followed by unclassified coronary heart disease (27.0%, 225.8 million), stable angina (17.1%, 143.0 million), STEMI (6.8%, 57.1 million), NSTEMI (6.3%, 52.6 million), AMI (1.5%, 12.5 million), and acute coronary syndrome (1.3%, 11.4 million). Total hospitalization costs for coronary heart disease were highest for unstable angina (40.8%, ¥48.64 billion), followed by unclassified coronary heart disease (18.8%, ¥22.32 billion), STEMI (13.3%, ¥15.83 billion), stable angina (12.3%, ¥14.68 billion), NSTEMI (10.6%, ¥12.63 billion), AMI (2.5%, ¥3.01 billion), and acute coronary syndrome (1.7%, ¥2.00 billion) [FIGURE:51].

In 2023, the average per capita hospitalization cost for CVD was ¥15,944.0, with materials accounting for the largest share (35.7%, ¥5,689.8), followed by diagnostics (21.5%, ¥3,421.5), medications (15.3%, ¥2,431.7), and treatment (13.7%, ¥2,179.2). Surgical treatment costs were significantly higher than non-surgical (¥1,705.6 vs ¥570.4), and Western medicine costs exceeded traditional Chinese medicine (¥2,100.9 vs ¥330.9). Surgical materials represented the highest material costs (¥4,229.4). Valvular heart disease had the highest per capita cost (¥71,274.3), followed by arrhythmia (¥30,067.6), coronary heart disease (¥14,234.6), heart failure (¥9,724.5), and hypertension (¥6,239.8). Material costs represented a higher proportion in coronary heart disease, arrhythmia, and valvular heart disease, while diagnostic costs were more prominent in heart failure and hypertension.

Among coronary heart disease subtypes, STEMI had the highest per capita total costs, diagnostic fees, treatment fees, and material costs, while AMI had the highest medication costs. Both overall coronary heart disease and its subtypes showed higher surgical than non-surgical treatment costs, higher Western than Chinese medicine costs, and surgical materials as the largest cost component.

The average CVD hospitalization duration was 8.3 days, longest for valvular heart disease (13.2 days), followed by heart failure (10.4 days), hypertension (8.9 days), coronary heart disease (7.8 days), NSTEMI (8.6 days), STEMI (8.3 days), stable angina (7.1 days), unstable angina (6.6 days), and arrhythmia (6.4 days).

Total 2023 CVD treatment costs were concentrated in older adults, with those aged ≥60 years accounting for 64.3% of costs. Based on the seventh national census, the cost proportion exceeded the population proportion starting at age 50, with the largest gap in the 70–79 age group (5.0% of population but 25.0% of costs) [FIGURE:53]. Among patients aged ≥30 years, coronary heart disease accounted for the highest cost proportion (60.7%), while arrhythmia costs were higher in those <30 years (46.8%) [FIGURE:54]. Males accounted for 60.5% of CVD treatment costs, with higher economic burdens than females across coronary heart disease, heart failure, arrhythmia, and valvular heart disease [FIGURE:55].

4.2 Cardiovascular Health Economics Evaluation

A study on return on investment for childhood and adolescent overweight and obesity prevention and treatment in China [38] used a deterministic Markov cohort model from a societal cost perspective to predict intervention impacts on morbidity and mortality from 2025–2092. Five evidence-based interventions were modeled: 20% sugar-sweetened beverage tax, restricting unhealthy food sales to children, breastfeeding promotion via text messages, school-based obesity interventions, and physician nutrition counseling. Without interventions, China faces 3.3 billion DALYs and ¥218 trillion in losses from 2025–2092, averaging ¥2.5 million per affected child. Full implementation of all five interventions could reduce DALY loss by 179.4 million and generate ¥13.1 trillion in economic benefits. Fiscal and regulatory policies (sugar-sweetened beverage tax and food sales restrictions) showed the highest return on investment, with economic benefits appearing within 10 years.

A decision-analytic simulation model evaluated the cost-effectiveness of pharmacological treatment for Chinese adults with blood pressure 130–139/80–89 mmHg and high cardiovascular risk [39]. Over 10 years, antihypertensive medication yielded 0.034 incremental quality-adjusted life years (QALY) compared with non-pharmacological treatment, with an incremental cost-effectiveness ratio (ICER) of $13,321.29/QALY, well below one times per capita GDP ($21,318), indicating high cost-effectiveness. Treatment remained highly cost-effective over a lifetime, with middle-aged and young adults benefiting most.

Conflicts of Interest: None declared.

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Received date: 2025-07-08; Revised date: 2025-07-31

Edited by: ZHANG Xiaolong