To implement the national policy of focusing on grassroots and prevention, and to promote a shift from hospitals to the community as the main locus of cardiovascular disease (CVD) prevention and control efforts, the National Center for Cardiovascular Diseases organizes compilation of the Report on Cardiovascular Health and Diseases in China by experts in related fields nationwide every year, to provide detailed scientific information and support for health administrators and professionals. In 2019, CVD accounted for 46.74% and 44.26% of the causes of death in rural and urban areas, respectively: two of every five deaths were due to CVD. The burden of CVD will continue to increase as China faces the dual pressures of an aging population and the continued increasing of metabolic risk factors. These pressures will affect disease prevention and control strategies and resource allocation, such as primary prevention efforts to decrease CVD incidence. In addition, they will require greater allocation of medical resources to address the rapidly increasing number of cardiovascular emergencies, and to provide rehabilitation and secondary prevention medical services aimed at decreasing the risk of recurrence, rehospitalization and disability among CVD survivors. The number of people with hypertension, dyslipidemia or diabetes in China has reached hundreds of millions. Moreover, the number of people requiring lifelong treatment with multiple drugs to prevent CVD is increasing. Further research is necessary to formulate more effective strategies to improve CVD awareness, treatment and control. Because most of these elevated risk factors are insidious, by the time they are detected, they have often led to vascular lesions or even more serious events, such as myocardial infarction and stroke. Although subclinical atherosclerosis are prevalent, vascular injury and treatment have not been a priority for prevention. A growing body of evidence suggests that maintaining vascular health is an important foundation for preventing CVD and degenerative disease. Therefore, strengthening the primordial prevention strategy for hypertension, dyslipidemia, diabetes, obesity, and smoking is of utmost importance. In addition, the assessment of cardiovascular health status and the prevention and control of early pathological changes should be strengthened.
According to the nationwide sampling surveys of hypertension conducted in 1958–1959, 1979–1980, 1991, and 2002, the crude prevalence rates of hypertension among people ≥ 15 years of age were 5.1%, 7.7%, 13.6%, and 17.6%, respectively, showing an increasing trend (Table 1). The results of the China Hypertension Survey (CHS) indicated a crude prevalence rate of hypertension in Chinese adults ≥ 18 years of age of 27.9% from 2012 to 2015, and the weighted rate of 23.2%. The estimated number of adults with hypertension in China is 245 million. The crude detection rate of high normal blood pressure is 39.1%, and the weighted rate is 41.3%. A total of 435 million people in China have been estimated to have high normal blood pressure.
Study name Year Age (years) Sampling method Sample size (people) Prevalence (%) Key project of Chinese
Academy of Medical
1958–1959 ≥ 15 Non-random sampling 739,204 5.1 National Hypertension
1979–1980 ≥ 15 Random sampling 4,012,128 7.7 National Hypertension
1991 ≥ 15 Stratified random sampling 950,356 13.6 China Health and
2002 ≥ 18 Multistage stratified cluster
272,023 18.8 Chinese Residents
Nutrition and Chronic
2012 ≥ 18 Multistage stratified
− 25.2 China Hypertension Survey 2012–2015 ≥ 18 Multistage stratified
451,755 27.9 (weighted rate 23.2) China Chronic Disease
2018 ≥ 18 Multistage stratified cluster
179,873 27.5 (weighted rate)
Table 1. Sampling survey on the prevalence of hypertension in China
In 2018, the China Chronic Disease and Risk Factor Surveillance (CCDRFS) project investigated 298 counties in 31 provinces, autonomous regions and municipalities in mainland of China and recruited 179,873 adults ≥ 18 years of age with a multi-stage stratified cluster random sampling method. The prevalence of hypertension was found to be 27.5%.
The CHNS prospective cohort study of 12,952 Chinese adults > 18 years of age has indicated that the age-standardised hypertension incidence increased from 40.8 per 1,000 person-years in 1993–1997 to 48.6 per 1,000 person-years in 2011–2015. From 1991 to 2011, CHNS conducted eight cross-sectional surveys on adults ≥ 18 years of age in 8 provinces of China (which increased to 9 in 1997 and 12 in 2011). The age standardized detection rate of high normal blood pressure increased from 23.9% in 1991 to 33.6% in 2011.
The CHS study has found that the hypertension awareness, treatment and control rates (weighted rates) in Chinese adults ≥ 18 years of age generally increased with age, and the treatment control rate first increased and then decreased (Figure 4). In 2015, the hypertension awareness, treatment and control rates among adults ≥ 18 years of age in China were 51.6%, 45.8%, and 16.8%, respectively. All of these rates showed significant improvements with respect to those reported in previous surveys . Studies of hypertension awareness, treatment and control rates in China over the years are shown in Table 2.
Study name Year Age
Sampling method Sample size
1991 ≥ 15 Multilevel random
950,356 27.0 12.0 3.0 China Health and
2002 ≥ 18 Multistage stratified
272,023 30.2 24.7 6.1 Chinese Residents
Nutrition and Chronic
2012 ≥ 18 Multistage Stratified
- 46.5 41.1 13.8 Chinese Residents
Nutrition and Health
2010–2012 ≥ 18 Multistage stratified
120,428 46.5 41.1 14.6 Investigation of
and control rates of
hypertension in the
2012–2013 18–60 Multistage cluster
2012–2015 ≥ 18 Multistage stratified
China Chronic Disease
and Risk Factor
2013–2014 ≥ 18 Multistage stratified
174,621 31.9 26.4 9.7 Early screening and
2014 35–75 Convenience sampling 640,539 46.5 (standardization rate) 38.1 (standardization rate) 11.1 (standardization rate) China Chronic
and Risk Factor
2018 ≥ 18 Multistage stratified
Table 2. Awareness, treatment, and control rates of hypertension in various studies
Figure 4. Awareness, treatment, control and treatment control rates regarding hypertension in different age groups in the China Hypertension Survey (CHS).
From 2005 to 2010, 12,497 adults were followed up for 5 years. After adjustment for other risk factors, the risk of hypertension in male drinkers was 1.236 times higher, and that in female drinkers was 1.409 times higher, than those in non-drinkers.
An investigation in eight provinces in China from 2007 to 2010, a cross-sectional study in 28 provinces from 2011 to 2012 and the China Health and Retirement Longitudinal Study (CHARLS) have all indicated that air pollution increases the risk of hypertension. The CHS has indicated that systolic blood pressure and diastolic blood pressure decrease by 0.74 mmHg (1 mmHg = 0.133 kPa) and 0.60 mmHg, respectively, for every 10 ℃ increase in ambient temperature.
A meta-analysis of 41 clinical studies on hypertension and depression has indicated a prevalence of depression in patients with hypertension of 28.5% in China.
A multicenter randomized controlled study published in the New England Journal of Medicine has indicated that, during a median follow-up of 3.34 years among 8,511 elderly patients with hypertension, 147 (3.5%) of the 4,243 patients in the intensive treatment group had primary outcome events, compared with 196 (4.6%) of the 4,268 patients in the standard treatment group (RR = 0.74). The rate of primary outcome events in the intensive treatment group was significantly lower than that in the standard treatment group, with an absolute difference of 1.1%.
Another study has found that, compared with standard hypertension control (targeting a blood pressure decrease to 140/90 mmHg), intensive hypertension control (targeting a blood pressure decrease to 133/76 mmHg) could avoid 2.209 million CHD events, 4.409 million stroke events and 75,100 cardiovascular deaths in 10 years. Compared to standard hypertension control, the intensive hypertension control could avert about 13% of stroke events, 17% of CHD events for males, and 11% of CHD events for females.
On the basis of China CVD policy modeling 2015–2025, if all patients with hypertension (with/without CVD, and stage I and II hypertension) were treated, as compared with the current treatment rates, 803,000 CVD events (690,000 cases of stroke and 113,000 cases of myocardial infarction) would be avoided, and 1.2 million quality adjusted life years (QALY) would be obtained.
For China, if the guidelines for the diagnosis and treatment of adult hypertension issued by the American College of Cardiology/American Heart Association in 2017 were adopted, to reach currently the treatment rate of hypertension. By preventing CVD events, the new guidelines will reduce the lifetime cost by US $3.77 billion and prevent the loss of 1.41 million life years due to disability.
A community multicenter prospective cohort study has evaluated the long-term antihypertensive efficacy, cost-effectiveness and cardiovascular outcomes of antihypertensive generic drugs and original drugs through propensity score matching and cost-effectiveness analysis. The average annual cost per patient in the generic drug group was significantly lower than that in the original drug group ($220.4 and $472.7, respectively). The average annual savings per patient with use of generic drugs was $252.3, whereas the effect on decreasing systolic blood pressure was similar between groups [(7.1 ± 1.0) mmHg and (7.9 ± 1.0) mmHg, respectively]. The cost-effectiveness ratio (annual average cost of decreasing systolic blood pressure by 1 mmHg at follow-up) in the generic and original drug groups were 31.0 and 59.8, respectively. Compared with that of generic drug treatment, the cost of original drug treatment was US $315.4 greater for each additional 1 mmHg decrease in systolic blood pressure.
From 2012 to 2015, the China Children and Adolescents Cardiovascular Health Survey (CCACH) used a screening strategy with three time points on different days to evaluate the prevalence of hypertension in 44,396 children 6–17 years of age from six cities in China. Although the prevalence of hypertension differed (17.1% vs. 15.4%) at a single time point screened according to the latest standards in China and the United States, the prevalence of hypertension after three consecutive blood pressure measurements on different days decreased by 79%, and the final prevalence of hypertension was similar (3.7% vs. 3.3%).
In a randomized controlled study of a nutrition and exercise intervention for hypertension prevention in children in grades 1–5 from 30 primary schools in five cities across the country, 15 schools served as the control group (3,333 people), and the other 15 schools served as the intervention group (3,431 people). The intervention group received population-based nutrition promotion (including nutrition courses, distribution of nutrition brochures and nutritional guidance provided to school cafeterias) and exercise promotion (at least 20 minutes of moderate- to high-intensity physical activity every day). One year later, children in the intervention group had a 0.9 mmHg lower systolic blood pressure and a 1.8% lower hypertension prevalence than the control group.
The results from 179,728 adults ≥ 18 years of age in the Chinese Adults Nutrition and Chronic Diseases Surveillance in 2015 have indicated that, the total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C) and triglyceride (TG) levels were higher than those in 2002 (Figure 5).
Figure 5. 13-year changes in blood lipid levels in Chinese adults ≥ 18 years of age. TC: total cholesterol; LDL-C: low-density lipoprotein cholesterol; HDL-C: high-density lipoprotein cholesterol; TG: triglyceride.
An analysis by the Non-communicable Disease Risk Factor Collaborative Group has found that in 1980, the average non-HDL-C level in the Chinese population was one of the lowest worldwide, whereas by 2018, it was about 4 mmol/L, reached or exceeded the non-HDL-C level in many high-income western countries.
In 2004 and 2014, 1,660 and 1,649 children and adolescents 6–18 years of age in Beijing were recruited in the Beijing Children and Adolescent Metabolic Syndrome Study. The levels of TC, LDL-C, non-HDL-C, and TG in children and adolescents in 2014 were significantly higher than those 10 years prior (Figure 6).
Figure 6. 10-year changes in blood lipid levels of children and adolescents 6–18 years of age in Beijing. TC: total cholesterol; LDL-C: low-density lipoprotein cholesterol; HDL-C: high-density lipoprotein cholesterol; TG: triglyceride
The CHNS in 2002, the China National Survey on Chronic Kidney Disease (CNSCKD) in 2019, the CHNS in 2011 and the Chinese Residents Nutrition and Chronic Disease Survey in 2012 have indicated that the overall prevalence of dyslipidemia (defined as the presence of any type of dyslipidemia, including TC ≥ 6.22 mmol/L, LDL-C ≥ 4.14 mmol/L, HDL-C < 1.04 mmol/L, and TG ≥ 2.26 mmol/L) in Chinese people ≥ 18 years of age has increased significantly, from 18.6% in 2002 to 40.4% in 2012.
The CHS was conducted in 29,678 residents ≥ 35 years of age from 2012 to 2015. The overall prevalence of dyslipidemia was 34.7%. The China National Stroke Screening and Prevention Project (CNSSPP) in 2014 indicated that the overall prevalence of dyslipidemia, standardized by age and sex, in Chinese residents ≥ 40 years of age was 43.0%. According to the data from the fourth CCDRFS 2013–2014 and the Chinese Adults Nutrition and Chronic Diseases Surveillance 2015, the main form of dyslipidemia in China are low HDL-C and high TG.
In 2012–2013, a survey was conducted on 16,434 children and adolescents 6–17 years of age from 93 primary and secondary schools in seven provinces, autonomous regions and municipalities in China. The total rate of dyslipidemia was 28.5% (cut points of TC > 5.18 mmol/L, LDL-C ≥ 3.37 mmol/L, HDL-C < 1.03 mmol/L, and TG > 1.7 mmol/L for dyslipidemia in children).
The CHS results in 2012–2015 indicated that the awareness, treatment and control rates for dyslipidemia in Chinese adults ≥ 35 years of age were 16.1%, 7.8%, and 4.0%.
The fourth CCDRFS recruited 163,641 adults ≥ 18 years of age. Totally 15,382 people were in the high-risk of dyslipidemia (9.4% of the total population), of which, 74.5% didn't achieve their LDL-C goal (< 2.6 mmol/L). While 2,945 people were in the extremely high-risk of dyslipidemia (accounting for 1.8% of the total population), and the failure rate of LDL-C was as high as 93.2% (LDL-C < 1.8 mmol/L was the standard) .
A total of 25,317 outpatients ≥ 45 years of age who had taken lipid-lowering drugs for at least 3 months were included in the Dyslipidemia International Study-China (DYSIS-China). The LDL-C treatment compliance rates for those with high or very high risk of atherosclerotic cardiovascular disease (ASCVD) were 44.1% and 26.9%, respectively.
The Improving Care for Cardiovascular Disease (CCC) in China project, from November 2014 to June 2017, enrolled 6,523 patients with recurrent ACS who had a history of MI or coronary revascularization from 150 tertiary hospitals. The statin treatment rate was only 50.8%, and 36.1% attained the LDL-C goal (< 1.8 mmol/L). The previous patients with ASCVD ≥ 75 years of age with recurrent ACS had only a 33.9% statin treatment rate and 24.7% had LDL-C < 1.8 mmol/L at admission[44-45].
The GBD 2017 has indicated that among the deaths caused by high LDL-C, 81.76% died from ischemic heart disease (IHD), while the remaining 18.24% from ischemic stroke. The population attributable fractions of high LDL-C for IHD deaths was 40.30%, and that for ischemic stroke deaths was 18.49%. The rate of deaths attributable to high LDL-C was 61.08/100,000. The number of disability-adjusted life years (DALY) attributable to high LDL-C was 18,162,100 person-years, of which 13,941,500 person-years (76.76%) were attributable to IHD. The DALY rate was 1,285.83/100,000.
In the Kailuan prospective cohort study, 51,407 people were followed up for an average of 6.84 years. The cumulative exposure time to elevated LDL-C (≥ 3.4 mmol/L) and the cumulative exposure value of LDL-C measured multiple times significantly increased the risk of new onset AMI, thus suggesting that the cardiovascular hazards of LDL-C showed a cumulative exposure effect, independently of the single LDL-C measurement value .
The CKB study has indicated that LDL-C levels are strongly positively correlated with ischemic stroke and strongly negatively correlated with cerebral hemorrhage (1 mmol/L decrease in LDL-C is associated with a 15% decrease in the relative risk of ischemic stroke and a 16% increase in the relative risk of cerebral hemorrhage). The above correlations have been further validated through Mendelian randomization analysis. The relative risk of ischemic stroke decreases by 25%, and the relative risk of cerebral hemorrhage increases by 13% with each 1 mmol/L decrease in LDL-C level associated with the genetic risk score. HDL-C levels are negatively associated with the risk of ischemic stroke (LDL-C and HDL-C are independently associated with ischemic stroke) and not with cerebral hemorrhage. TG levels are weakly positively associated with the risk of ischemic stroke and negatively associated with cerebral hemorrhage.
A study in 21,265 adults (35–64 years of age) without ASCVD in a multi-provincial cohort study in China, classified according to the 10-year ASCVD risk assessment of the Chinese Guidelines for the Prevention and Treatment of Dyslipidemia in Adults (2016 Revision), has indicated that low-dose statin intervention decreased the 10-year ASCVD incidence rate by 4.1%, 9.7%, and 15.5%, respectively in the low, moderate and high risk groups. Lowering statin prices to the level of the centralized procurement policy of the central government in 2019 could significantly decrease the incremental cost-effectiveness ratio (ICER) for all risk groups; thus, the cost-effectiveness of statins for primary prevention of ASCVD could be significantly improved.
From 1980 to 2017, China conducted several surveys on the prevalence of diabetes (Figure 7). A population-based survey with 300,000 people in 1980 indicated a prevalence of diabetes of 0.67%. From 2015 to 2017, a cross-sectional survey of 75,880 adults over 18 years of age in 31 provinces, autonomous regions and municipalities has indicated that, on the basis of WHO diagnostic criteria, the prevalence rate of diabetes in Chinese adults was 11.2% (95% CI: 10.5%–11.9%), and the detection rate of prediabetes was 35.2% (95% CI: 33.5%–37.0%). According to the American Diabetes Association standard, the prevalence of diabetes was 12.8% (95% CI: 12.0%–13.6%): the prevalence of previously diagnosed diabetes was 6.0% (95% CI: 5.4%–6.7%), and the prevalence of newly diagnosed diabetes was 6.8% (95% CI: 6.1%–7.4%). An estimated 129.8 million adults have diabetes in China (70.4 million men and 59.4 million women).
Figure 7. Investigation of the prevalence of diabetes in China. *: prevalence of diabetes in the urban population.
In a study based on the diabetes surveillance system in Zhejiang province, analysis of the data for 879,769 newly diagnosed cases of type 2 diabetes from January 1st, 2007 to December 31th, 2017 revealed an age standardized total incidence of type 2 diabetes of 281.73/100,000 person-years (95% CI: 281.26–282.20). The standardized annual incidence rate increased from 164.85/100,000 person-years in 2007 to 268.65/100,000 person-years in 2017, with an average annual increase of 4.01%, and a faster increase in men, young adults, and people in rural areas.
The Daqing Diabetes Prevention Study in China enrolled 577 adults with impaired glucose tolerance from 33 clinics, who were identified through oral glucose tolerance tests. The participants were randomly assigned to either a control group or one of three intervention groups (diet, exercise or diet plus exercise). Interventions were started in 1986 and completed in 1992. Subsequently, participants were followed for up to 30 years to assess the effects of the interventions. Compared with the control group, the combined intervention group had a median delay in diabetes onset of 3.96 years, a 39% lower incidence of diabetes, 26% fewer CVD events, a 35% lower risk of composite microvascular events, 33% fewer CVD deaths and a 26% lower risk of all-cause death. The incidence of stroke and severe retinopathy in the intervention group was also significantly lower than that in the control group. The average life expectancy of the intervention group was increased by 1.44 years compared with the control group.
Mathematical models estimated that a nationwide lifestyle intervention for the pre-diabetic population would be highly efficacious, resulting in a 9.53% decrease in cumulative diabetes incidence, an 0.82 year increase in mean life expectancy, a 0.52 year increase in QALY, a $700 decrease in mean total cost and an incremental cost-effectiveness ratio of -$1,339/QALY .
A national cross-sectional survey conducted from September 2009 to September 2010 among 47,204 adults > 18 years from 13 provinces, autonomous regions and municipalities in China has assessed the prevalence of chronic kidney disease (CKD). The overall prevalence of CKD was 10.8%. Therefore, the number of patients with CKD in China was estimated to be approximately 120 million. The adjusted prevalence of an estimated glomerular filtration rate (eGFR) < 60 mL/(min·1.73 m²) was 1.7%, and that of a urinary albumin to creatinine ratio > 30 mg/g was 9.4%.
The CHARLS from 2015 to 2016 included 6,706 participants ≥ 60 years of age with reduced renal function [eGFR < 60 mL/(min·1.73 m²)]. The overall prevalence of reduced renal function was 10.3% and increased with age (60–64 years: 3.3%; 65–69 years: 6.4%; 70–74 years: 11.4%; 75–79 years: 22.2%; and > 80 years: 33.9%).
The China Kidney Disease Data Network (CK-NET) 2016 annual report indicated that the proportion of hospitalized patients with a comorbid CKD diagnosis was 4.86% of the total hospitalized patients in that year. The prevalence of CKD was 13.90% in patients with diabetes, 11.41% in those with hypertension, and 7.96% in those with CVD. A total of 18.82% of hospitalized patients with CKD had CHD, 16.91% had heart failure (HF), 13.22% had stroke, and 4.01% had atrial fibrillation (AF).
In 2016, the median cost for inpatients with CKD was RMB 15,405 (IQR: RMB 8,435–RMB 29,542), which was higher than that for those without CKD RMB 11,182 (IQR: RMB 5,916–RMB 18,922). The average cost for patients with hemodialysis was RMB 89,257, and that for patients with peritoneal dialysis was RMB 79,653.
A total of 98,042 participants ≥ 18 years old were included in the analysis of the 2010–2012 China National Nutrition and Health Survey in 31 provinces, autonomous regions and municipalities in mainland of China. Metabolic syndrome (MS) was defined according to the US National Cholesterol Education Program Adult Treatment Panel III criteria (NCEP ATP III). The prevalence of MS was 24.2%.
In the China National Nutrition and Health Survey 2010–2012, data were collected in 16,872 adolescents 10–17 years of age. According to the diagnostic criteria proposed by the Pediatric Branch of the Chinese Medical Association, the prevalence of MS was 2.4%. The prevalence of MS was 4.3% according to the Cook criterion.
Ambient air pollution and indoor air pollution are the 3rd and 13th greatest risk factors affecting DALY in China. Compared with 1990 values, the total number of deaths associated with indoor air pollution decreased by 72.7%, and DALY losses decreased by 80.2%, in 2019.
From 2000 to 2016, more than 30 million excess deaths in China have been attributed to long-term exposure to PM2.5, with annual excess deaths of 1.5 million–2.2 million.
A study on the evaluation of long-term PM2.5 exposure and related disease burden at the national level has shown that the number of deaths caused by PM2.5 pollution in China reached 30.08 million from 2000 to 2016. Since 2013, the total number of deaths caused by PM2.5 exposure in China has gradually decreased.
A series of studies based on data on air pollution and causes of mortality in 272 cities in China from 2013 to 2015 have reported that an increased risk of CVD mortality is associated with an increase in PM2.5 and coarse particulate matter (diameter 2.5–10.0 μm), O3, SO2, NO2, and CO. In addition, air pollution can increase the risk of CVD mortality and hypertension[58-61].
From a prospective cohort study in 226,000 urban residents in China, residents who used solid fuels rather than clean fuels (gas or electricity) for cooking had a 19% greater risk of all-cause mortality, a 24% greater risk of CVD mortality and a 43% greater risk of respiratory disease mortality. Moreover, kitchen ventilation decreased the risk of all-cause mortality by 19% and the risk of CVD mortality by 25%.
The prevalence of CVD in China is increasing. The number of patients with CVD is estimated to be 330 million: 13 million with stroke, 11.39 million with CHD, 8.9 million with HF, 5 million with pulmonary heart disease, 4.87 million with AF, 2.5 million with rheumatic heart disease, 2 million with congenital heart disease, 45.3 million with lower extremity arterial disease and 245 million with hypertension.
The mortality of CVD in rural areas has exceeded that in urban areas since 2009 (Figure 8A). CVD was the main cause of death among rural and urban residents. In 2019, CVD accounted for 46.74% and 44.26% of deaths in rural and urban areas, respectively (Figure 8B). Two of five deaths were attributable to CVD.
Figure 8. Changes in the mortality due to cardiovascular diseases among urban and rural residents in China from 2000 to 2019 (A) and the constituent ratios of major causes of death among urban and rural residents in China in 2019 (B).
In 2019, the mortality due to CVD in rural areas was 323.29/100,000: 164.66/100,000 due to heart disease and 158.63/100,000 due to cerebrovascular disease (Figure 9A). The mortality due to CVD in urban areas was 277.92/100,000: 148.51/100,000 due to heart disease and 129.41/100,000 due to cerebrovascular disease (Figure 9B).
According to China Health Statistics Yearbook 2020, in 2019, the mortality due to CHD was 121.59/100,000 among urban residents and 130.14/100,000 among rural residents. The mortality due to CHD has been increasing since 2012. The mortality due to CHD in rural areas increased significantly and exceeded that in urban areas by 2016 (Figure 10A).
Figure 10. Trends in mortality due to coronary heart disease (CHD) (A) and acute myocardial infarction (B) in urban and rural areas of China from 2002 to 2019.
From 2002 to 2018, the mortality due to AMI showed an increasing trend, but a slight decrease was observed in 2019. The rate has increased rapidly since 2005. The mortality due to AMI in rural areas not only exceeded that in urban areas in 2007, 2009, and 2010, but also increased significantly since 2012. In 2013, the mortality of AMI in rural areas exceeded that in urban areas (Figure 10B).
According to the 5th National Health Services Survey in China, 2013, the prevalence of CHD among Chinese residents ≥ 15 years of age was 10.2‰, and that in people over 60 years of age was 27.8‰. Compared with that in the 4th data in 2008 (7.7‰), the total prevalence increased. There would be 11.40 million patients with CHD among Chinese residents ≥ 15 years of age. This number was 1.08 million more than the number of patients with CHD across all age groups in 2008, as calculated from the data from the 4th National Health Services Survey.
In the China PEACE study, 162 secondary and tertiary hospitals were randomly selected from 31 provinces, autonomous regions and municipalities in China, and 13,815 medical records were included in. In the 10 years from 2001 to 2011, the number of ST-segment elevation myocardial infarction (STEMI) inpatients increased each year per 100,000 people in China. In the general population, the hospitalization rate for STEMI increased from 3.7/100,000 in 2001 to 8.1/100,000 in 2006 and 15.8/100,000 in 2011. Significant geographical differences in the medical process and results for patients with AMI have been observed in China and found to persist at 2001, 2006, 2011, and 2015.
The China Acute Myocardial Infarction (CAMI) Registry study has indicated significant differences in the treatment and outcomes of patients with STEMI in different levels of hospitals in China. Compared with that in provincial hospitals, the proportion of patients with STEMI receiving reperfusion treatment in prefectural and county-level hospitals was lower, and the proportion of in-hospital deaths was higher.
The China Clinical Pathway of Acute Coronary Syndrome study (CPACS) enrolled 15,140 patients with ACS in 70 hospitals in 17 provinces, autonomous regions and municipalities in China. The application rate of standardized secondary preventive drugs in ACS patients after discharge decreased each year. The application rate at discharge was 86%, then decreased to 68% 1 year later and to 59.7% 2 years later.
A study of 3,387 patients within 24 h after AMI onset in 53 hospitals in various regions of the country has reported a readmission rate within 30 days of 6.3%, nearly 50% of which occurred within 5 days after discharge. A total of 77.7% of patients were hospitalized because of cardiovascular events, including angina pectoris (31.2%), HF (16.7%), and AMI (13.0%).
China PEACE has demonstrated that Chinese patients with AMI have a high recurrence rate of early myocardial infarction after discharge. The recurrence rate of myocardial infarction within 1 year is 2.5%, of which 35.7% of cases occur within 30 days after discharge. The 1-year mortality of patients with recurrent myocardial infarction increased by 25.42 times, and the 1-year mortality of patients with early recurrent myocardial infarction was highest (53.5%).
The China Acute Myocardial Infarction (CAMI) study analyzed data for 80 hospitals that admitted ≥ 50 patients with STEMI and were able to provide emergency percutaneous coronary intervention (PCI) from 2013 to 2016. A total of 29,581 patients with STEMI were admitted to these hospitals, and the in-hospital mortality was 6.3%. Combined with the Chinese guidelines for STEMI diagnosis and treatment and the American myocardial infarction quality standard, the opportunity-based composite score (OBCS) indicated in-hospital mortality of patients with STEMI in lower OBCS (< 71.1%), moderate OBCS (71.1%–76.5%) and higher OBCS (> 76.5%) hospitals of 7.2%, 6.6%, and 5.4%, respectively.
According to the data from hospital quality monitoring system (HQMS) for 10,259,521 CVD related inpatients (excluding those in military and traditional Chinese medicine hospitals) in 1,910 tertiary public hospitals (accounting for 79.5% of all tertiary public hospitals in China) and 2,124 secondary public hospitals (accounting for 35.9% of all secondary public hospitals in China) performed CVD diagnosis and treatment, there were 1,014,266 patients treated with PCI in China in 2020.
According to data from 87 heart centers nationwide enrolled in the China Cardiac Surgery Registration, a total of 56,776 patients received coronary artery bypass grafts from 2013 to 2016, and the total in-hospital mortality after the procedure was 2.1%.
From 2017 to 2019, a multi-center cross-sectional study, conducted in nine locations in China on more than 6,000 patients who underwent coronary angiography or CT angiography, has indicated that facial features are associated with an increased risk of CAD. The team has developed and verified a deep learning algorithm based on facial photos to detect CAD, which can assist in identifying CAD and is expected to be used in outpatient CAD probability assessment or community CAD screening.
Cerebrovascular disease is a major cause of death in China, reaching 2,189,175 cases in 2019. Compared with those in 2009, the number of deaths increased by 12.4%. In 2019, 3,935,182 new stroke cases and 28,760,186 patients with stroke in China were reported. Stroke was also the primary cause of DALY in 2019. The number of DALY reached 45,949,134, and the age standardized DALY rate was 2,412.52/100,000.
In 2019, the crude mortality due to cerebrovascular disease among Chinese residents was 149.56/100,000, accounting for 22.17% of total deaths, and ranking third among major causes of death, after malignant tumors (162.46/100,000) and heart disease (160.26/100,000).
The crude mortality due to cerebrovascular disease among urban residents in China was 129.41/100,000, accounting for 20.61% of the total urban deaths; that among rural residents was 158.63/100,000, accounting for 22.94%. The crude mortality rate due to cerebrovascular disease in men was higher than that in women, and that in rural areas was higher than that in urban areas.
From 2003 to 2019, the crude mortality due to cerebrovascular disease in rural areas was higher than that in urban areas. Compared with the rate in 2006, the crude mortality due to cerebrovascular disease in 2009 increased by 1.41 times in urban areas and 1.44 times in rural areas. The crude mortality due to cerebrovascular disease showed a decreasing trend from 2009 to 2012, but increased slightly from 2013 to 2019, and was significant in rural areas (Figure 11).
Figure 11. Trends in crude mortality of cerebrovascular disease in urban and rural residents in China from 2003 to 2019.
From 1997 to 2015, the CHNS analysis of 15,917 residents indicated an age standardized stroke incidence rate of 4.17/1,000 person-years in the north and was statistically significantly lower in the south, at 1.95/1,000 person-years. This difference was found in rural areas rather than urban areas. Hierarchical model analysis suggested that regional differences could be explained by differences in hypertension prevalence.
The transient ischemic attacks (TIA) epidemiological survey in 2013 involved face to face surveys of 178,059 families in 155 disease surveillance sites. A total of 595,711 people were analyzed for TIA incidence. The weighted incidence rate of TIA was 23.9/100,000: 21.3/100,000 in men and 26.6/100,000 in women. A total of 310,000 new TIA cases have been estimated to occur in China every year.
According to an epidemiological survey in 2013, the prevalence rate of stroke in China was 1,596.0/100,000, and the age standardized prevalence rate was 1,114.8/100,000; the rates were higher in rural areas (1,291.1/100,000) than in urban areas (814.4/100,000). The highest prevalence rate of stroke was in central China (1,549.5/100,000), followed by northeast China (1,450.3/100,000) and northern China (1,416.5/100,000), whereas the lowest rate was in South China (624.5/100,000).
The 2019 annual cerebrovascular disease surveillance platform has identified a total of 291,632 inpatients with acute ischemic stroke in 31 provinces nationwide; intravenous thrombolysis rate of recombinant plasminogen activator for those who arrived within 4.5 h of onset was 30.4%, and the in-hospital mortality rate was 0.4% (Table 3).
Medical quality indicators n (%) Process indicators Thrombolytic rate of rt-PA in patients who came to the hospital within 4.5 hours of onset 22,400 (30.4) Prevention rate of deep venous thrombosis in patients unable to walk within 48 hours after admission# 9,266 (12.0) Dysphagia screening rate 231,089 (80.7) Rehabilitation evaluation rate 212,028 (74.0) Antithrombotic treatment rate at discharge 251,035 (88.7) Anticoagulation treatment rate for patients with atrial fibrillation at discharge 9,166 (45.9) Statin treatment rate for patients with non-cardiogenic cerebral infarction at discharge 248,258 (90.7) Antihypertensive treatment rate for patients with hypertension at discharge 143,232 (64.9) Hypoglycemic drug treatment rate for patients with diabetes at discharge 63,678 (78.4) Outcome indicators Hospitalization mortality 1,066 (0.4) Note. rt-PA, recombinant plasminogen activator. #The number of patients unable to walk on their own within 48 h after admission within a unit time who received prophylaxis for deep vein thrombosis (anticoagulants and/or combination intermittent inflation and compression) accounted for the proportion of hospitalized patients who could not walk by themselves in the same period.
Table 3. Medical quality indicators for inpatients with acute ischemic stroke in 2019
According to the data statistics of the online registration system of the National Health Commission and the data reported by the provincial quality control center, during the COVID-19 pandemic, 86,181 cardiac pacemakers were implanted nationwide in 2020, representing a 4.8% decrease with respect to 2019, of which dual chamber pacemakers accounted for 73%. The indications for pacemaker implantation mainly included sick sinus syndrome (55.0%), atrioventricular block (41.5%) and other indications (3.5%). Clinical research on the feasibility, safety and effectiveness of His-Purkinje system pacing, including His bundle or left bundle branch pacing, in patients with bradyarrhythmia has rapidly progressed in China. Left bundle branch pacing technology originated in China and has been described in more than 70 academic articles in international CVD related journals since 2019.
According to CHS, from 2012 to 2015, the prevalence of AF was 0.7% in Chinese residents ≥ 35 years of age, and was higher in rural (0.75%) than urban (0.63%) residents. A total of 34% of the patients were diagnosed with AF for the first time and were unaware of their condition.
A survey of 1,252,703 adults over 40 years of age by the China stroke screening survey from 2013 to 2014 has indicated that 12% of Chinese patients with ischemic stroke had AF. On the basis of this calculation, more than 2.15 million Chinese patients with ischemic stroke had AF, and the proportion of these patients receiving anticoagulation therapy was very low, at only 2.2%, of which 98.2% of patients used warfarin.
The Chinese Atrial Fibrillation Registry study analyzed 7,977 patients with non-valvular AF in 32 hospitals from 2011 to 2014. The proportions of oral anticoagulation use were 36.5%, 28.5%, and 21.4% for patients with CHA2DS2-VASc scores ≥ 2, 1, and 0, respectively. These proportions varied from 9.6% to 68.4% in tertiary hospitals and from 4.0% to 28.2% among nontertiary hospitals.
According to data from the AF registration research platform, the proportion of radiofrequency catheter ablation in patients with AF increased each year, accounting for 27.3%, 31.9%, 33.0%, and 32.2% of the total ablations in 2017, 2018, 2019, and 2020, respectively. Circumferential pulmonary vein isolation remained a major procedure, accounting for 60.2% of total ablations. The incidence of periprocedural ischemic stroke was 0.4%, and that of hemorrhagic stroke was 0.1%.
Radiofrequency catheter ablation has been widely used in more than 600 hospitals in China. According to the online registration system of the National Health Commission, the number of radiofrequency catheter ablation operations has continued to grow rapidly since 2010, with an annual growth rate of 13.2% to 17.5%. During the COVID-19 pandemic, the number of radiofrequency ablation operations in 2020 was 102,864, a number significantly lower than those in previous years. In 2020, the ablation rate for supraventricular tachycardia was 40.7%, and the radiofrequency ablation rate for AF was 32.2%—essentially the same as that in 2019.
A prospective study has monitored 678,718 participants from July 2005 to June 2006. At the 1-year follow-up, 284 (9.5%) sudden cardiac death (SCD) had occurred among 2,983 total deaths. The overall annual incidence of SCD was 41.8/100,000, and was higher in men than in women (44.6/100,000 vs. 39.0/100,000). On the basis of this project, SCD was estimated to account for more than 500,000 deaths in China annually.
According to the statistics of the online registration system of the National Health Commission and the data reported by the provincial quality control center, the implantation of implantable cardioverter defibrillators (ICD) decreased slightly in 2020 during the COVID-19 pandemic, compared with 2019 (4,800 cases vs. 5,031 cases). In 2020, single chamber accounted for 50% of ICD, while primary prevention accounted for 53% and secondary prevention accounted for 47%.
Among 230 patients with long QT syndrome (LQTS) from ten hospitals in China, LQT1 (KCNQ1 mutation, 37%), LQT2 (KCNH2 mutation, 48%) and LQT3 (SCN5A mutation, 2%) were the main subtypes.
The Chinese Ion Channelopathy Registry and International Project Collaborative Group Study have indicated that the probands’ mean age of onset was 17.3 ± 14.2 years; 60% had an onset before the age of 20 years, and 76% were women. Children with LQTS had a high degree of malignancy, with a clinical phenotype mostly presenting as complex arrhythmias and a pathogenic or likely pathogenic mutated gene detection rate of 71%. In southwest China, 33.7% of patients with sudden unexplained death carried LQTS associated mutated genes (KCNQ1 and KCNH2).
In a domestic health screening study among employed people 20–50 years of age, the detection rate of early repolarization ranged from 2.73% to 3.99% and was more frequent in men, with a higher occurrence in those with moderate or higher labor intensity. The detection rate of early repolarization in the ECG screening of 13,405 high school or college students was 1%, and was more frequent in men than women. Early repolarization occurred most frequently in inferior wall leads, followed by inferior and lateral wall leads, with a morphology of predominantly contusive and notch type. During a follow-up period of 12–36 months, no students experienced cardiovascular events, such as sudden cardiac death, or arrhythmia. An analysis of electrocardiograms of 1,215 students in competitive sports programs has indicated an early repolarization rate of 35.9%; early repolarization was more common in men, occurred most frequently in inferior wall leads and mostly showed contusive morphology.
From October 2012 to December 2015, 31,499 residents ≥ 35 years of age received echocardiography in a study using a stratified multistage random sampling method. A total of 1,309 people had valvular heart disease, and the weighted prevalence of valvular heart disease was 3.8%. Approximately 25 million patients have been estimated to have valvular heart disease in China. Rheumatic valvular disease remains the main cause of valvular heart disease in China, and the number of patients with degenerative valvular disease has significantly increased in recent years. Among Chinese patients with valvular heart disease, 55.1% had rheumatic valvular disease, and 21.3% had degenerative valvular disease (Figure 12).
Figure 12. Proportion of valvular heart diseases due to different causes in the indicated age groups.
Researchers from Zhongshan Hospital Affiliation to Fudan University analyzed the data for 325,910 patients who underwent transthoracic echocardiography in the hospital from January 2011 to December 2015. A total of 3,673 patients (1.13%) were diagnosed with bicuspid aortic valve, accounting for 69.1% of men, 58.4% of patients with definite aortic valve insufficiency, 52.5% of patients with ascending aortic dilatation and 19.2% of patients with aortic root dilatation.
Congenital heart disease ranks first among neonatal birth defects in many areas of China. Regional differences exist in the detection rate of congenital heart disease, and rates vary primarily between 2.9‰ and 16‰.
A meta-analysis of the detection rate and spatial distribution characteristics of neonatal congenital heart disease in China including data on 76,961,354 neonates in 617 studies from 1980 to 2019 has indicated that the detection rate of national neonatal congenital heart disease increased from 0.201‰ in 1980–1984 to 4.905‰ in 2015–2019. The detection rate of congenital heart disease increased gradually from the west to the east, and decreased gradually from the south to the north.
A survey of 122,765 newborns from 12 hospitals in eastern China and 6 hospitals in western China from August 2011 to November 2012 has indicated a detection rate of neonatal congenital heart disease in China of 8.98‰, with a higher rate in girls (11.11‰) than in boys (7.15‰).
According to China Health Statistics Yearbook 2020 , in 2019, the mortality rate due to congenital heart disease in urban residents in China was 0.76/100,000, and that in rural areas was higher, at 0.91/100,000.
In 2020, according to the data from 714 hospitals performing cardiac surgery in China (including Hong Kong Special Administrative Region) collected by the cardiopulmonary bypass branch of the Chinese Society of Biomedical Engineering, a total of 62,704 patients received surgery for congenital heart disease, accounting for 28.2% of all cardiac and aortic surgeries, and the proportion showed a decreasing trend, thus causing congenital heart disease to fall to second place among diseases receiving cardiovascular surgery treatment for the first time (Figure 13). This decrease might have been associated with the decline in the number of births and the birth rate every year, and the popularity of prenatal diagnosis and prenatal screening. The number of heart surgeries performed in patients under 18 years of age was 37,665, accounting for 60.1% of the total number of congenital heart disease surgeries in 2020, representing a decrease of 6.5% compared with 2019. Thus, adult congenital heart disease correction surgery is increasing each year, accounting for a high proportion of cardiovascular surgeries in China.
According to the data from the National Health Commission's network direct report system for interventional treatment of congenital heart disease and the military's network direct report system for interventional treatment of congenital heart disease, the total number of interventional treatments for congenital heart disease in mainland of China in 2019 was 39,027. Among them, the number of interventional treatments of congenital heart disease in local hospitals in mainland of China in 2019 was 34,758, representing an increase of 5.45% with respect to 2018. The treatment success rate was 98.41%, the incidence of serious complications was 0.12%, and the mortality was 0.01%. Overall, the number of cases of interventional treatment for congenital heart disease in local hospitals in China showed a slow increasing trend. In 2019, the number of local hospitals performing interventional treatment for congenital heart disease in mainland of China reached 313, and the number of physicians performing this treatment reached 483.
From October 2001 to February 2002, a stratified cluster sampling survey was conducted among 8,080 residents (including 4,064 men and 4,016 women) in nine provinces and cities of China. The crude prevalence rate of hypertrophic cardiomyopathy (HCM) was 0.16%. The prevalence of HCM in men (0.22%) was higher than that in women (0.10%). After adjustment for age and sex, the prevalence rate was 80/100,000. On the basis of these data, more than 1 million adult patients have been estimated to have HCM in China.
According to a survey of nine provinces (regions), the prevalence of dilated cardiomyopathy (DCM) in China is 19/100,000. From July 2011 to December 2011, a total of 49,751 residents were investigated in 120 villages in non-Keshan disease areas of seven provinces in northern China. A total of 6 DCM cases were detected, and the estimated prevalence rate was 1.2/10,000.
The Chinese Society of Cardiology analyzed 10,714 patients with HF from 42 hospitals in China in 1980, 1990, and 2000, and found proportions of DCM of 6.4%, 7.4%, and 7.6%, respectively.
A survey by the Cardiovascular Group of the Pediatric Branch of the Chinese Medical Association has reported that a total of 4,981 children with cardiomyopathy were admitted to 33 hospitals in China from July 2006 to December 2018, accounting for 0.079% (4,981/6,319,678 cases) of pediatric hospitalized children in the same period. DCM accounted for the most cases [1,641 (32.95%)], followed by endocardial fibroelastosis (EFE) [1,283 (25.76%)] and left ventricular non-compaction (LVNC) [635 (12.75%)]. The overall number of inpatients is increasing each year (Figure 14).
Figure 14. Annual number of pediatric inpatients with cardiomyopathy in 33 hospitals in China from 2006 to 2018.
In a domestic study, 529 patients with HCM were subjected to gene detection. It was found that 43.9% of the patients could be detected definite pathogenic mutations, among which, MYH7 and MYBPC3 genes accounted for the largest proportion. In 2020, a study at the Fuwai Hospital of the Chinese Academy of Medical Sciences found that common genetic variants are also important contributors to HCM, thus suggesting a non-Mendelian inheritance pattern with ethnic specificityy.
Arrhythmogenic cardiomyopathy (ACM) is mainly caused by mutations in the gene encoding desmoglein. Domestic studies have shown that pathogenic mutations can be detected in 63.3% of patients with ACM, of which PKP2 accounted for the largest proportion. It was found that the founder mutation p.Phe531Cys of the homozygous DSG2 gene was a risk factor for China ACM, which was at a frequency of 8% with a full penetrance. Homozygous c.245G > A/p.G82D mutation in the PNPLA2 gene is associated with the phenotypic penetrance of ACM.
A study has retrospectively analyzed all fetuses with non-compaction of ventricular myocardium (NCCM) diagnosed antenatally from October 2010 to December 2019. A total of 37 cases of NCCM were identified in 49,898 fetuses, and the detection rate of NCCM was 0.07%. Among them, 47% had positive gene testing results, most of which were non-sarcomere gene mutations. No mutations were found in the three sarcomere genes most common in children and adults (MYH7, TTN, and MYBPC3).
A survey among 15,518 residents from 20 urban and rural areas in China showed that the prevalence of chronic HF was 0.9% in the population aged 35–74 years in 2000.
CHS analyzed 22,158 participants , and found that the prevalence rate of HF was 1.3% among adults aged 35 years or older. The prevalence of left ventricular systolic dysfunction (LVEF < 50%) was 1.4%, and that of moderate/severe diastolic dysfunction was 2.7%.
China Heart Failure (China-HF) Registry Study enrolled 13,687 patients with HF from 132 hospitals in China from January 2012 to September 2015, and the in-hospital mortality was 4.1%. In the China Heart Failure Medical Quality Control Report in 2020, an analysis of 33,413 patients with HF with recorded hospital outcomes, who were treated at 113 hospitals nationwide from January 2017 to October 2020, has indicated a mortality of 2.8% among hospitalized patients.
From January 2011 to September 2012, 3,335 patients with acute HF in 14 hospitals in Beijing were followed up for 5 years. The 5-year all-cause mortality rate was 55.4%, the CVD mortality rate was 49.6%, and the median survival time was 34 months.
According to the China Heart Failure Medical Quality Control Report in 2020 , the average age of patients with HF was 67 ± 14 years, and men accounted for 60.8%. The proportion of valvular disease in patients with HF has decreased each year. Hypertension (56.3%) and CHD (48.3%) have become the main causes of HF in China. Infection is the primary cause of HF, followed by myocardial ischemia and fatigue. HF with decreased ejection fraction, with intermediate ejection fraction and with preserved ejection fraction accounted for 40.2%, 21.8%, and 38.0%, respectively.
The overall usage rate of diuretics in hospitalized HF patients in China had not changed significantly. The usage rate of digoxin had shown a downward trend due to the influence of international clinical studies. In the meantime, the usage rate of aldosterone receptor antagonists and β-receptor blockers had increased significantly. The overall usage rate of renin angiotensin system (RAS) blockers showed an upward trend, but because of the advent of angiotensin receptor enkephalinase inhibitor (ARNI), the usage rate of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor antagonist (ARB) decreased (Table 4).
Research source Investigation year Sample size
Utilization rate of therapeutic drugs (%) Nitrate Diuretics Digitalis ARB ACEI ARNI MRA β receptor
42 hospitals in China 1980 1,756 44.7 73.7 51.7 0.4 14.0 − 10.0 8.5 6.1 1990 2,181 36.0 70.2 45.5 1.4 26.4 − 8.4 9.5 16.4 2000 6,777 53.0 48.6 40.3 4.5 40.4 − 20.0 19.0 10.5 Hubei 2000−2010 16,681 − 69.1 46.2 18.7 51.6 − − 46.6 − 10 hospitals 2005−2009 2,154 53.2 74.4 57.6 Total 66.0 − 74.6 68.3 46.1 Kunming 2008−2012 2,106 − 84.8 28.2 Total 82.8 − 76.6 72.2 − Xinjiang Uygur
2011−2012 5,357 − 45.5 26.8 Total 72.8 − 46.6 66.8 − China-HF study 2012−2015 13,687 41.4 72.2 − 28.8a 71.7b − 74.1b 70.0b − 51.3c 49.4c 48.7c 52.2c Heart failure quality
2007−2020 33,413 − 75.0 29.3 Total 44.0 36.9 87.8 82.2 − Note. a, Intravenous medication during hospitalization; b, Oral drugs used in patients with HFrEF after discharge; c, Oral drugs used in patients with HFpEF after discharge; ACEI: Angiotensin-converting enzyme inhibitor; ARB: Angiotensin II receptor antagonist; MRA: Mineralocorticoid receptor antagonist; ARNI: Angiotensin receptor enkephalinase inhibitor. −: Not reported.
Table 4. Drug application in patients with heart failure
According to statistics from the online registration system of the National Health Commission of China and the data reported by the provincial quality control center, the number of cardiac resynchronization therapy (CRT) implants in 2020 was 3,896, representing a decrease of 13.9% with respect to 2019. The proportion of CRT-D implantations increased each year, because patients who met CRT-P indications also met CRT-D indications. From 2013 to 2015, 454 cases of CRT-P/D from 22 centers in China were included in a study, and 52.2% of the patients chose CRT-D. The proportion of CRT-D in patients treated with CRT in 2019 further increased to 64%. The ratio of CRT-D was higher in hospitals with an annual number of implants exceeding 40 and lower in areas with lower GDP.
To date, nearly 100 implantable left ventricular assist device operations have been performed in 16 hospitals in China. Among them, the National Medical Products Administration has approved only three registration clinical trials on the evaluation of the safety and effectiveness of artificial heart treatment of end-stage HF.
The first was the EVAHEART I clinical trial study, led by the Fuwai Hospital of the Chinese Academy of Medical Sciences, produced by Chongqing Yongren Heart. From January 2018 to January 2021, 17 EVAHEART I implantations were performed, and no patients died during the perioperative period. During the long-term follow-up, two patients received heart transplantation 156 days and 1,035 days postoperatively, respectively, and the other 15 patients survived for 350–1,100 days with the artificial heart.
The second was the CH-VAD clinical trial study, led by the Fuwai Hospital of the Chinese Academy of Medical Sciences, produced by Suzhou Tongxin. From January 2019 to December 2020, 33 CH-VAD implantations were performed at five centers. Three patients died during the perioperative period, and the remaining 30 patients had recovered to NYHA I or II by 1 month postoperatively. During the long-term follow-up, one patient had the device removed 166 days after cardiac function recovery, one patient had the device removed and received heart transplantation 190 days postoperatively, and the other 28 patients survived for 360–1,600 days with the device.
The third was a clinical trial on the safety and effectiveness of "rocket heart" in the treatment of end-stage HF, produced by Hangtian Taixin. A total of 50 cases have been enrolled, and the specific data remain to be published.
According to data from the China heart transplantation registration system, a total of 56 medical institutions in China were qualified to perform heart transplantation as of 2020. From 2015 to 2020, the annual numbers of heart transplant procedures implemented and reported by transplantation centers in China were 279, 368, 446, 490, 679, and 557, respectively. A total of 2,819 procedures were completed and reported in 6 years (excluding Hong Kong, Macao, and Taiwan, China). In 2020, non-ischemic cardiomyopathy was present in 74.4% of heart transplantation recipients in China and 84.9% of pediatric heart transplant recipients. In 2020, the in-hospital survival rate among Chinese heart transplant recipients was 88.5%, and multiple organ failure and transplant HF accounted for more than 60% of the early causes of death. From 2015 to 2020, the 1-year survival rate after heart transplantation in China was 85.3%, and the 3-year survival rate was 80.4%. The 1-year survival and 3-year survival rates after heart transplantation in adults were 85.3% and 80.4%, respectively, and those in children were 91.0% and 84.0%, respectively.
4.9.1 Pulmonary Hypertension From May 2007 to October 2010, 551 adult patients with pulmonary hypertension (PH) were enrolled in a national multicenter study, including 487 patients (88.4%) with pulmonary arterial hypertension (PAH) and 64 patients (11.6%) with chronic thromboembolic pulmonary hypertension (CTEPH). The PAH subtypes comprised 273 cases (56.1%) of congenital heart disease-related PAH (PAH-CHD), 64 cases (13.1%) of connective tissue disease-related PAH (PAH-CTD) and 150 cases (30.8%) of idiopathic pulmonary hypertension (IPAH).
According to the data from the Chinese Systemic Lupus Erythematosus (SLE) Treatment and Research group (CSTAR) in 2014, with PH defined as a resting pulmonary artery systolic pressure ≥ 40 mmHg, as measured by echocardiography, the prevalence of PAH was 3.8% (74/1,934) in patients with SLE.
Before 2006, no targeted drug for PAH was available in China. The 1-, 3-, and 5-year survival rates of IPAH and familial PAH were 68.0%, 38.9% and 20.8%, respectively. In the era of targeted drugs, the survival status of IPAH has improved significantly, with 1- and 3-year survival rates for IPAH of 92.1% and 75.1%, respectively.
4.9.2 Pulmonary Thromboembolism and Deep Venous Thrombosis From 1997 to 2008, 18,206 of the 16,972,182 hospitalized patients in more than 60 tertiary hospitals in China were diagnosed with pulmonary embolism (PE), accounting for 0.11% of hospitalized patients. The PE mortality in China in 1997–2008 decreased significantly, from 25.1% in 1997 to 8.7% in 2008.
In a study on venous thromboembolism (VTE) hospitalization and mortality rates in China, a total of 105,723 patients with VTE were enrolled from 90 hospitals in mainland of China from January 2007 to December 2016; 43,589 (41.2%) of the cases were PE combined with DVT, and 62,134 cases (58.7%) were simple deep venous thrombosis (DVT). The age and sex adjusted hospitalization rate increased from 3.2/100,000 in 2007 to 17.5/100,000 in 2016. The in-hospital mortality rate decreased from 4.7% in 2007 to 2.1% in 2016 (Figure 15), and the hospitalization time decreased from 14 days to 11 days.
Figure 15. Inpatient rate (A) and inpatient mortality rate (B) for venous thromboembolism in China from 2007 to 2016.
In the China Pulmonary Thromboembolism Registry Study (CURES) from 2009 to 2015, a total of 7,438 adult hospitalized patients with acute symptomatic pulmonary embolism treated at medical institutions in 31 provinces, autonomous regions and municipalities were included. High-risk (hemodynamic instability), moderate-risk [simplified pulmonary embolism severity index (sPESI) ≥ 1] and low-risk (sPESI = 0) patients accounted for 4.2%, 67.1%, and 28.7%, respectively. CT pulmonary angiography was the most commonly used diagnostic method (87.6%), and anticoagulation therapy was the most commonly used initial treatment method (83.7%). The proportion of initial systemic thrombolytic therapy decreased from 14.8% to 5.0%, and the mortality of acute pulmonary embolism decreased from 3.1% to 1.3%.
The Identification of Chinese Hospitalized Patients' Risk Profile for Venous Thromboembolism (Dissolve-2) study enrolled a total of 13,609 patients—6,623 (48.7%) from internal medicine departments and 6,986 (51.3%) from surgical departments—who were hospitalized for more than 72 hours due to medical or surgical emergencies from 60 tertiary hospitals in China from March to September in 2016. According to the 9th version of the CHEST Guidelines, the risk of VTE among medical inpatients was divided into low-risk (63.4%) and high-risk (36.6%) groups, and the risk of VTE among surgical inpatients was divided into low-risk (13.9%), moderate-risk (32.7%) and high-risk (53.4%) groups. The main VTE risk factor for surgical inpatients was open surgery (52.6%), whereas the main VTE risk factor for medical inpatients was acute infection (42.2%). The proportion of all patients receiving the preventive measures recommended in the 9th version of the CHEST Guidelines was 14.3% (19.0% of surgical patients and 9.3% of medical patients), whereas 10.3% (11.8% of surgical patients and 6.0% of medical patients) received appropriate preventive measures.
4.10.1 Aortic Disease According to Chinese health insurance data in 2011, the annual incidence of acute aortic dissection in the mainland of China was approximately 2.8/100,000, and was significantly higher in males than in females (3.7/100,000 vs. 1.5/100,000).
The results of a domestic registration study of aortic dissection (Sino-RAD) have indicated that the average age of Chinese patients with aortic dissection is approximately 51.8 years—an age approximately 10 years younger than that in Europe and America. For type A aortic dissection, the open surgery treatment rate was 89.6%, the drug treatment rate was 7.8%, the endovascular treatment rate was 1.6%, the hybrid treatment rate was 1.3%, and the in-hospital mortality rate was 5.5%. For type B aortic dissection, the rate of drug therapy alone was 21.3%, and the mortality rate was 9.8%. The surgical treatment rate was 4.4%, and the mortality rate was 8.0%. The intracavitary treatment rate was 69.6%, and the mortality rate was 2.5%.
Different types of aortic dissection require different surgical methods, and their hospitalization days and hospitalization costs are also different. According to HQMS, in 2020, the averagestay length of thoracic endovascular aneurysm repair (TEVAR) in China was 15.9 days, and the average hospitalization cost was RMB 157,500. The average stay length of simple graft replacement of ascending aorta with aortic valve (Bentall surgery) was approximately 23.4 days, and the average hospitalization cost was RMB 211,600. The average stay length of patients undergoing total aortic arch replacement was approximately 23.2 days, and the average hospitalization cost was RMB 274,100.274,100.
Screening of 5,402 people ≥ 40 years of age with relevant risk factors in three urban and two rural communities in central China has indicated a prevalence of abdominal aortic aneurysm of 0.33% in people 55–75 years of age—a value higher than those in the other age groups (0.51% vs. 0.11%). A cross-sectional survey conducting abdominal aortic ultrasound screening on a total of 3,560 people > 60 years of age in four cities in Liaoning province has reported a positive detection rate of abdominal aortic aneurysm of 0.9%.
A meta-analysis on the growth rate of Chinese abdominal aortic aneurysms  showed that the annual growth rate of abdominal aortic aneurysms in the Chinese population is 0.18–0.75 cm. The larger the diameter of the aneurysm, the faster the growth rate was.
According to HQMS, in 2020, the average stay length of abdominal aortic prosthesis replacement surgery in China was 22 days, and the average hospitalization cost was RMB 123,000. The average stay length of endovascular abdominal aortic repair (EVAR) was 14 days, and the average hospitalization cost was RMB 178,400.
4.10.2 Peripheral Arterial Disease
220.127.116.11 Lower Extremity Arterial Disease (LEAD)
A stratified random sampling survey in mainland of China has indicated a prevalence rate of LEAD in the general population ≥ 35 years of age of 6.6%. On the basis of these data, the number of patients with LEAD in China has been inferred to be approximately 45.3 million. Among them, 1.9% of the patients received revascularization. A total of 860,000 patients in China have been estimated to receive revascularization.
18.104.22.168 Carotid Atherosclerotic Disease
In 2018, the results of carotid ultrasonography in 106,918 urban and rural community residents ≥ 40 years of age were collected and analyzed in the Chinese Stroke Prevention Program (CSPP). The data show that the prevalence rate of moderate and above carotid stenosis was 0.5% .
According to the China Stroke Prevention and Control Report in 2019, the number of reported cases of carotid endarterectomy (CEA) in 2018 was 4,910, and the rate of serious complications of the operation was 2.79%. In 2018, a total of 15,801 carotid artery stenting procedures were performed, and the incidence of serious complications was 1.92%.
22.214.171.124 Renal Artery Stenosis
A single center study involving 2,905 patients with renal artery stenosis (RAS) for 18 years has found that the main causes of RAS in Chinese population are atherosclerosis (82.4%), Takayasu arteritis (11.9%), fibromuscular dysplasia (4.3%) and other causes (1.4%). AS increased from 50% in 1999–2000 to 85% in 2015–2016. Non-AS causes were more common in patients below less than 40 years old.
126.96.36.199 Subclavian Artery Stenosis
An inter-arm systolic blood pressure difference ≥ 15 mmHg is a powerful index for predicting subclavian artery stenosis > 50%, and can be used for epidemiological screening and diagnosis of subclavian artery stenosis. A study of 3,133 elderly people with an average age of 69 years in a community in Shanghai has indicated that 1.7% of the population had an inter-arm systolic pressure difference ≥ 15 mmHg. A single center study has investigated the etiological composition of subclavian artery stenosis in hospitalized patients and found that AS accounted for 95.9% in patients above 40 years of age, whereas the main cause in patients younger than 40 years of age was Takayasu arteritis (90.5%).
A large cohort study of 710,000 cancer patients has reported that 18% of patients had CVD risk factors or CVD: 13% of patients with cancer had at least one CVD risk factor, and 5% had one type of CVD. After adjustment for age, sex, tumor stage and treatment received, patients with HF had the poorest prognosis, with a 79% increase in all-cause mortality, followed by myocardial infarction, with a 50% increase in all-cause mortality.
Report on Cardiovascular Health and Diseases in China 2021: An Updated Summary
- Received Date: 2022-06-28
- Accepted Date: 2022-07-13
- Cardiovascular disease /
- Epidemiology /
- Health influencing factors /
- Risk factors /
- Prevalence /
- Mortality /
- Community-based prevention and control /
- Rehabilitation /
- Basic research /
- Medical device development
Abstract: In 2019, cardiovascular disease (CVD) accounted for 46.74% and 44.26% of all deaths in rural and urban areas, respectively. Two out of every five deaths were due to CVD. It is estimated that about 330 million patients suffer from CVD in China. The number of patients suffering from stroke, coronary heart disease, heart failure, pulmonary heart disease, atrial fibrillation, rheumatic heart disease, congenital heart disease, lower extremity artery disease and hypertension are 13.00 million, 11.39 million, 8.90 million, 5.00 million, 4.87 million, 2.50 million, 2.00 million, 45.30 million, and 245.00 million, respectively. Given that China is challenged by the dual pressures of population aging and steady rise in the prevalence of metabolic risk factors, the burden caused by CVD will continue to increase, which has set new requirements for CVD prevention and treatment and the allocation of medical resources in China. It is important to reduce the prevalence through primary prevention, increase the allocation of medical resources for CVD emergency and critical care, and provide rehabilitation services and secondary prevention to reduce the risk of recurrence, re-hospitalization and disability in CVD survivors. The number of people suffering from hypertension, dyslipidemia and diabetes in China has reached hundreds of millions. Since blood pressure, blood lipids, and blood glucose levels rise mostly insidiously, vascular disease or even serious events such as myocardial infarction and stroke often already occured at the time of detection in this population. Hence, more strategies and tasks should be taken to prevent risk factors such as hypertension, dyslipidemia, diabetes, obesity, and smoking, and more efforts should be made in the assessment of cardiovascular health status and the prevention, treatment, and research of early pathological changes.
|Citation:||The Writing Committee of the Report on Cardiovascular Health and Diseases in China. Report on Cardiovascular Health and Diseases in China 2021: An Updated Summary[J]. Biomedical and Environmental Sciences, 2022, 35(7): 573-603. doi: 10.3967/bes2022.079|