The Chinese edition of the Annual Report on Cardiovascular Health and Diseases in China 2020 has been published. We present herein an interpretation of this report.
Factors influencing cardiovascular health
About 1.9 million avoidable deaths from coronary heart disease (CHD) per year (approximately one-fifth of all CHD deaths globally) are attributable to tobacco use and exposure to secondhand smoke (SHS). An estimated 382,000 people died of CHD attributable to SHS exposure, representing 4.3% of all deaths from CHD.
The prevalence of current smoking among Chinese residents aged ≥15 years was 28.1% in 2010 and dropped to 26.6% in 2018. It was 50.5% in males and 2.1% in females, and was higher in rural areas (28.9%) than in urban areas (25.1%). The highest prevalence was found in the population aged 45 to 64 years (30.2%), whereas the lowest was among those with a college education or above (20.5%).
In 2019, the overall prevalence of current smokers was 5.9% among secondary school students, with 3.9%, 5.6%, and 14.7% for students in junior high school, senior high school, and vocational senior high school, respectively. Compared with the 2014 youth survey, the prevalence of current smokers and experimental smokers among junior high school students in 2019 decreased by 33.9% (5.9% vs. 3.9%) and 27.9% (17.9% vs. 12.9%), respectively.
The rate of SHS exposure among nonsmokers in China was 68.1% in 2018, of whom 35.5% were exposed to SHS almost every day. Internet cafes (89.3%), bars and nightclubs (87.5%), and restaurants (73.3%) were the most common indoor public places with severe exposure to SHS. The rate of SHS exposure had declined in comparison with that in 2010 (72.4%).
In 2018, 86.0% of people believed that smoking could cause serious diseases. The awareness of specific diseases caused by smoking ranked from high to low was lung cancer (82.8%), heart disease (50.8%), stroke (41.4%), and impotence (26.0%). Moreover, 71.4% of people thought that SHS could also cause serious diseases. The awareness of these diseases ranked from high to low was childhood pulmonary disease (66.7%), adult lung cancer (65.8%), and adult heart disease (39.7%).
The prevalence of smoking cessation among Chinese smokers was 18.7% in 2015 and increased to 20.1% in 2018. It was lower in males (19.6%) than in females (30.2%). No significant difference was found between urban (20.0%) and rural areas (20.3%). The prevalence of smoking cessation in the young age group was relatively low.
In 2018, 50% of smokers spent no more than 9.9 China Yuan (CNY) on a packet of cigarettes (10.0 CNY in urban areas and 8.4 CNY in rural areas). From 2015 to 2018, the ratio of the median cost on 100 packets of cigarettes to the gross domestic product per capita decreased from 2.0% to 1.5%.
The relative risk (RR) of death associated with cigarette smoking among the Chinese population was 1.23 (95% confidence interval (CI): 1.18–1.27), with 1.18 (95% CI: 1.13–1.23) in males and 1.27 (95% CI: 1.19–1.34) in females. The population-attributable risk (PAR) was 7.9%, with 10.0% in males and 3.5% in females.
An analysis of 2 Chinese prospective studies 15 years apart revealed that the proportional excess mortality among male smokers approximately doubled over this 15-year period. The annual number of deaths in China that are caused by tobacco smoking will rise from about 1 million in 2010 to 2 million in 2030 and 3 million in 2050 unless there is widespread cessation.
By January 2020, more than 20 cities had implemented local regulations on tobacco control in China, but only 13 cities including Beijing, Shanghai, Shenzhen, Qingdao, Lanzhou, Changchun, Xi’an, Wuhan, Qinhuangdao, and so on, met the requirements of Framework Convention on Tobacco Control, which covers about 10% of the national population.
According to the Beijing Medical Claim Data for Employees from January 2013 to June 2017 (including 29 months before and 25 months after enforcement of the tobacco-control policy), after implementation of the policy, immediate reductions were observed in in-hospital admissions for acute myocardial infarction (MI) (−5.4%, 95% CI: −10.0% to −0.5%) and stroke (−5.6%, 95% CI: −7.8% to −3.3%). In addition, the secular increase trend for stroke was slowed down by −15.3% (95% CI: −16.7% to −13.9%) annually. Compared with the hypothetical scenario in which the policy had not taken place, an estimated 18,137 (26.7%) hospital admissions for stroke had been averted during the 25 months of the postpolicy period.
The World Health Organization (WHO) has been advocating 3 to 10 minutes of brief interventions for smoking cessation in routine healthcare. However, this recommendation is not practicable for Chinese physicians, who are very busy. The China Adult Tobacco Survey 2018 indicated that only 46.2% of current smokers had been provided with advice on smoking cessation by their physicians during medical consultations.
A randomized controlled trial was conducted in 13,671 Chinese adults who were daily cigarette smokers from 2015 to 2017. It demonstrated the effectiveness of physicians’ very brief smoking-cessation intervention (30-second advice plus printed materials). The intervention (vs. control) group had greater self-reported 7-day abstinence (9.1% vs. 7.8%, odds ratio (OR) 1.14, 95% CI: 1.03–1.26, P = 0.008).
Nutrition and health-surveillance data of Chinese residents indicated that the energy from dietary carbohydrate, protein, and fat was sufficient during 2010 to 2012. Four China National Nutrition Surveys (CNNSs) from 1982 to 2012 and China Health and Nutrition Survey (CHNS) 1991 to 2015 showed that the daily protein intake had not changed significantly. The mean percentage of energy from total fat continued to increase (it was 32.9% in 2012 and exceeded the maximum recommended amount by Chinese Dietary Guidelines (20%–30%)), whereas that from carbohydrate decreased greatly (it was 55.0% in 2012 and reached the minimum recommendations (55.0%–65.0%)). The imbalance of energy intake from dietary nutrients was more severe in urban residents than in rural ones.
Nutrition and health-surveillance data of Chinese residents indicated that grain intake was sufficient during 2010 to 2012, but the dietary pattern remained unhealthy. On the one hand, the daily intake of whole grains, tubers, fresh vegetables, fruits, dairy products, seafood, soybeans, nuts, and so on was inadequate. On the other hand, the average consumption of cooking oil and dietary sodium was far above the recommendation.
In 2012, the mean consumption of refined grains among Chinese adults aged ≥20 years was 304 g/day, and that of whole grains was 14.6 g/day. They both decreased. The daily intake of fruit, fresh vegetables, vegetable oil for cooking, animal oil for cooking, dairy products, and soybeans was 40.7 g, 269 g, 37.3 g, 4.8 g, 24.7 g, and 14.2 g, respectively. All of them were at a suboptimal level.
In 2012, the daily sodium intake remained high among Chinese adults (5702 mg), which corresponded to 14.5 g of dietary salt. The proportion exceeding the maximum recommended amount for prevention of chronic noncommunicable diseases (<5 g/day) was 88.3%. The proportion of urban and rural residents with suboptimal intake of vitamin A, vitamin B1, vitamin B2, vitamin C, calcium, magnesium, and selenium was up to 77.0%, 77.8%, 90.2%, 67.7%, 96.6%, 60.6%, and 70.8%, respectively.
The proportion of Chinese residents with weekly intake of soft drinks ≥1 time was 59.2%, which was significantly higher than that in 2002 (14.2%). It was quite common that adolescents aged 6 to 17 years to consume soft drinks, and the proportion with daily intake ≥1 time was 18.3%.
According to data from CNNS 2010 to 2012, of all dietary factors attributed to mortality from cardiovascular metabolic diseases (CHD, stroke, and type-2 diabetes mellitus (T2DM)), high-sodium intake was the leading dietary risk factor for cardiometabolic mortality with a population-attributable fraction of 17.3%, followed by low intakes of fruits (11.5%), marine omega-3 fat (9.7%), nuts (8.2%), whole grains (8.1%), and vegetables (7.3%).
According to data from CNNSs 1982, 1992, 2002, and 2010 to 2012, there was a relatively large improvement in the population-attributable fraction of 12 dietary factors associated with cardiometabolic mortality in Chinese adults, from 62.2% in 1982 to 51.0% in 2012. However, taking into account population growth and aging, the absolute number of cardiometabolic deaths due to unhealthy diet increased substantially, from 1.07 million in 1982 to 1.51 million in 2010 to 2012.
Global Status Report on Alcohol and Health 2018 released by the WHO demonstrated that in 2016, the alcohol per capita consumption was 7.2 L of pure alcohol among the Chinese population aged ≥15 years and 12.9 L for current drinkers only. The prevalence of heavy episodic drinking (ie,consuming at least 60 g of pure alcohol on at least one occasion in the past 30 days) was 22.7%. It was 40.7% for current drinkers only, and higher in males than in females.
The prospective China Kadoorie Biobank (CKB) enrolled 512,715 adults between 2004 and 2008, and followed them for about 10 years. It found no apparently protective effects of moderate intake of alcohol against cardiovascular diseases (CVDs). Alcohol consumption uniformly increased blood pressure (BP) and stroke risk.
Physical activity (PA)
PA and Fitness in China—The Youth Study was conducted among Chinese school-aged children and adolescents in 2016 and 2017, respectively. A multistage cluster-sampling method was used to recruit students (more than 120,000 participants in 2016 and 130,000 in 2017) from primary, junior middle, and junior high schools across all administrative provinces in mainland China. In 2017, 34.1% of children and adolescents met the guidelines for moderate-vigorous PA, which was slightly higher than that in 2016.
In 2016, 85.2% of students in primary, junior middle, and junior high schools had ≥2 classes of physical education every week, and 31.5% of them took part in ≥5 times of extracurricular sports training every week. The prevalence of daily screen-viewing time ≥2 hours spent on television, mobile telephone, or computer among school-aged children was 8.7%, 11.5%, and 9.0%, respectively, on weekdays; at weekends, it increased to 23.7%, 27.7%, and 17.5%, respectively. These estimates were higher in boys than in girls.
Data from the Chinese National Survey on Students’ Constitution and Health 1985 to 2014 (which covered 738,523 Chinese Han students aged 13–18 years) indicated, according to National Standards for Students’ Physical Health, the overall prevalence of excellent health status and physical fitness increased from 2.7% in 1985 to 4.4% in 1995, dropped consistently to 1.1% in 2005, rebounded slightly in 2010, and increased to 2.2% in 2014.
In 2014, the prevalence of regular PA was 33.9% among Chinese residents and 14.7% in those aged ≥20 years. It was higher in urban areas (19.5%) than in rural ones (10.4%). The lowest prevalence was in the group aged 20 to 39 years, whereas the highest was in those aged 60 to 69 years.
From 1991 to 2009, the total PA among Chinese adults fell from 385.9 metabolic equivalent of task (MET) hours per week to 212.8 MET hours per week, but the time spent on sedentary behaviors increased from 15.1 hours per week to 20.0 hours per week. From 1991 to 2011, the occupational PA decreased by 31% in male adults, and a similar decline was observed in females.
Among Chinese residents, higher total PA was associated with a significantly lower risk of CVD death. The adjusted hazard ratio (HR) for the top (≥33.8 MET-h/day) versus bottom (≤9.1 MET-h/day) quintile of baseline total PA was 0.59 (95% CI: 0.55–0.64) for CVD-related death. Each 4 MET-h/day higher-than-usual total PA was associated with a 12% lower risk of CVD death.
In 2013, physical inactivity cost healthcare systems international-dollar 4.86 billion in China, accounting for about 10.0% of global costs. The direct and indirect costs were $3.08 billion and $1.78 billion, respectively. Of the direct healthcare costs attributable to physical inactivity, 55.8% was paid by the public sector, 10.3% by the private sector, and 33.9% by households.
The prevalence of overweight and obesity among Chinese children aged ≤6 years was 8.4% and 3.1%, respectively, in 2013. It increased by 1.9% and 0.4%, respectively, compared with the estimates in 2002.
The Chinese National Survey on Students Constitution and Health had been conducted 6 times during 1985 to 2014. The combined prevalence of overweight and obesity among Chinese adolescents increased continuously. It was 19.4% among those aged 7 to 18 years in 2014. The prevalence of overweight and obesity in 2014 was 11 and 56 times of that in 1985, respectively.
The prevalence of overweight and obesity among Chinese residents aged ≥18 years was 30.1% and 11.9%, respectively, in 2012. It increased by 32.0% and 67.6%, respectively, when compared with the data in 2002. The increase in rural areas was higher than that in cities.
The China Hypertension Survey (CHS) was conducted from 2012 to 2015. The prevalence of abdominal obesity (defined as a waist circumference ≥90 cm for males and ≥85 cm for females) was 29.1% among residents aged ≥18 years, 28.6% in males, and 29.6% in females. The number of adults with abdominal obesity was estimated to be 277.8 million.
The CKB study found that maintenance of a normal body mass index (BMI) was associated with a reduction in the risk of a major coronary event by 5.8%, ischemic heart disease (IHD) by 7.8%, ischemic stroke (IS) by 4.5%, and T2DM by 34.4%, respectively. Compared with normal waist circumference (<85.0 cm for males and <80.0 cm for females), central obesity (waist circumference ≥90 cm for males and ≥85 cm for females) was associated with an increase in the risk of IHD by 29%, major coronary event by 30%, and IHD death by 32%. Using BMI <24.0 kg/m2 as the low-risk definition, 36.0% of incident DM was attributable to overweight/obesity.
In 2019, high BMI accounted for 549,500 CVD deaths in China. The age-standardized CVD death rate was 38.64 per 100,000. Of CVD deaths, 11.98% were attributable to high BMI.
In 2003, the total medical cost attributable to overweight and obesity in China was estimated to be 21.11 billion CNY, and accounted for 25.5% of the total medical costs of 4 chronic diseases: hypertension, CHD, T2DM, and stroke. In 2010, overweight and obesity imposed a substantial economic burden of 90.768 billion CNY on China and was responsible for 42.9% of the annual costs of 5 major noncommunicable diseases: hypertension, CHD, T2DM, stroke, and cancer. The economic costs of overweight and obesity accounted for 4.5% of the national health expenditure.
By the end of 2017, 5.81 million Chinese adults had been registered as having severe mental health problems. From 1990 to 2017, the all-age prevalence of depression per 100,000 rose from 3224.6 to 3990.5. In 2017, the prevalence in females (5039.6) was significantly higher than that in males (2984.9).
According to data from cardiovascular outpatients of tertiary general hospitals of 5 Chinese cities in 2014, the adjusted prevalence of depressive and anxiety disorder was 4.05%, and that of the depressive and/or anxiety disorder was 14.27%.
A meta-analysis found that, in 23 hospital-based studies, the prevalence of depression in CHD patients in hospital was 51% (95% CI: 43%–58%) in China, and that of severe depression was 0.5% to 25.44%. The prevalence of depression in CHD patients from the community ranged from 34.6% to 45.8%, and that of the severe depression was from 3.1% to 11.2%.
The INTERHEART study indicated that the prevalence of depression in China was 21.66% among patients with acute MI, which was significantly higher than that among controls (10.36%). Although the prevalence of depression among cases and controls was lower in China than that in 51 other countries, the associated risk of acute MI was significantly higher in Chinese people (China: OR = 2.27, 95% CI: 1.95–2.65; other countries: OR = 1.37, 95% CI: 1.28–1.47; P < 0.001).
A CKB study showed that the overall prevalence of major depression was 0.61% among Chinese adults. Major depression was an independent risk factor for IHD (HR = 1.32, 95% CI: 1.15–1.53). The association was more evident in urban than rural residents (HR = 1.72, 95% CI: 1.39–2.14).
Researchers from Shanghai Mental Health Center analyzed the data of 3273 patients with major depressive disorder from 32 hospitals in China. The prevalence of circulatory-system complaints was 31.3% if depression was one of the major somatic symptoms, which also included insomnia, gastrointestinal system complaints, trunk pain, sensory system complaints, nervous symptom complaints, hyposexuality, limb pain, and so on.
Cardiovascular risk factors
Data from nationwide surveys of hypertension in 1958 to 1959, 1979 to 1980, 1991, and 2002 revealed that the crude prevalence of hypertension among the Chinese population aged ≥15 years was 5.1%, 7.7%, 13.6%, and 17.6%, respectively, demonstrating a general upward trend [Table 1].
Table 1 -
Nationwide surveys on the prevalence of hypertension
|Key project of Chinese Academy of Medical Sciences—hypertension research
|National hypertension sampling survey
|National hypertension sampling survey
||Stratified random sampling
|China Health and Nutrition Survey
||Multistage stratified cluster random sampling
|Chinese Residents’ Nutrition and Chronic Disease Survey
||Multistage stratified random sampling
|China Hypertension Survey
||Multistage stratified random sampling
||27.9 (weighted: 23.2)
According to CHS 2012–2015, the overall crude prevalence of hypertension among Chinese adults aged ≥18 years was 27.9% (weighted prevalence, 23.2%). The crude prevalence was 5.1% among adults aged 18 to 34 years and 59.8% in those aged ≥75 years [Figure 1]. It was estimated that 244.5 million of the Chinese adult population aged ≥18 years had hypertension. The awareness, treatment, and control rates of hypertension had improved markedly in the last 3 years [Table 2].
Table 2 -
Awareness, treatment, and control of hypertension in different studies
||Awareness rate (%)
||Treatment rate (%)
||Control rate (%)
|National Hypertension Sampling Survey
||Stratified random sampling
||Multistage stratified cluster random sampling
|Chinese Residents’ Nutrition and Chronic Disease Status Survey
||Multistage stratified cluster random sampling
||Multistage stratified cluster random sampling
|Survey on prevalence, awareness, treatment and control rates of hypertension among Chinese working population
||Multistage cluster sampling
||57.6 (standardized rate: 47.8)
||30.5 (standardized rate: 20.6)
||11.2 (standardized rate: 8.5)
||Multistage stratified random sampling
||51.6 (weighted rate: 46.9)
||45.8 (weighted rate: 40.7)
||16.8 (weighted rate: 15.3)
||Multistage stratified random sampling
||46.5 (standardized rate)
CCDRFS: China Chronic Disease and Risk Factors Surveillance; CHNS: China Health and Nutrition Survey; CHS: China Hypertension Survey; China PEACE: China Patient-centered Evaluative Assessment of Cardiac Events.
Data from 9 provinces (increased to 12 provinces by 2011) in China indicated that the age-adjusted prevalence of prehypertension among Chinese adults aged ≥18 years increased from 23.9% in 1991 to 33.6% in 2011. According to CHS 2012 to 2015, the overall crude prevalence of prehypertension among Chinese adults aged ≥18 years was 39.1% (weighted prevalence, 41.3%). It was estimated that 435.3 million of Chinese adults had prehypertension.
In 2013, the total health expenditure in China was 3186.9 billion CNY, of which the direct economic burden of hypertension accounted for 6.6%. It was estimated that the community healthcare or standardized management of hypertensive patients could reduce the average annual drug cost and hospitalization cost by around 26 CNY and 245 CNY, respectively, and thereby would save the annual direct medical expense per capita for hypertension around 210 CNY. Annual investment of 800 CNY per capita in community health management of hypertension in China can produce positive net benefits, that is, the output is greater than the input.
High systolic BP accounted for 2.54 million deaths in China in 2017, with 95.7% of these deaths being due to CVDs. Treating all patients with stage-1 and stage-2 hypertension would prevent about 803,000 CVD events (690,000 strokes and 113,000 MIs) and gain about 1.2 million quality-adjusted life years (QALYs) annually compared with the status quo.
From 2010 to 2016, the number of hypertensive patients with standardized management in China doubled from 42.159 million to 90.23 million. The prevalence of standardized management among hypertensive patients reached 70.31%.
BP references by age and height for Chinese children aged 3 to 17 years (Chinese standards) issued in 2017 performed equally or better compared with other standards in predicting adult subclinical CVD, and was recommended as the diagnostic criterion for identification of Chinese children with elevated BP [Table 3].
Table 3 -
China Formula Standard for screening hypertension in children and adolescents aged 3 to 17 years
||Systolic blood pressure (mmHg)
||Diastolic blood pressure (mmHg)
||100 + 2 × age
||65 + Age
||100 + 1.5 × age
||65 + Age
Data from Chinese National Survey on Students’ Constitution and Health (CNSSCH) 2010 showed that the prevalence of high blood pressure was 14.5% among Chinese school-aged children: 16.1% for boys and 12.9% for girls.
According to data from 9 rounds of CHNS 1991 to 2015, among Chinese school-aged children in surveillance areas, systolic BP increased from 96.1 mmHg in 1991 to 102.7 mmHg in 2015, diastolic BP from 62.6 mmHg to 67.4 mmHg, and the prevalence of hypertension from 8.9% to 20.5%.
Obesity is the leading risk factor for primary hypertension among children and adolescents. Analysis of the data from 943,128 Chinese school-aged children of Han ethnicity showed that the PAR of hypertension because of being overweight and obesity increased steadily from 6.3% in 1995 to 19.2% in 2014, and the PAR for systolic hypertension increased from 7.4% to 26.2% [Figure 2].
According to the data of 179,728 participants aged ≥18 years eligible for analysis in Chinese Adults Nutrition and Chronic Diseases Surveillance in 2015 (CANCDS 2015), the mean levels of total cholesterol (TC), triglyceride (TG), and low-density lipoprotein-cholesterol (LDL-C) increased significantly in comparison with those in CNHS 2002 (n = 49,233) [Figure 3].
Data from CHNS 2002, China National Survey of Chronic Kidney Disease in 2010 (CNSCKD 2010), CHNS 2011, and Report on Chinese Residents’ Chronic Diseases and Nutrition 2012 showed that the prevalence of dyslipidemia (defined as the presence of any type of dyslipidemia) in Chinese adults aged ≥18 years was 18.6%, 34.0%, 39.91%, and 40.4%, respectively. CHS 2012–2015 indicated that the prevalence of dyslipidemia was 34.7% among adults aged ≥35 years across China. Findings from the China National Stroke Screening and Prevention Project in 2014 revealed that the age- and sex-standardized prevalence of dyslipidemia was 43% among residents aged ≥40 years.
Results from the fourth China Chronic Disease and Risk Factor Surveillance (CCDRFS) 2013 to 2014 and CANCDS 2015 showed that low levels of high-density lipoprotein-cholesterol (HDL-C) and high TG levels were 2 major types of dyslipidemia in Chinese adults. The prevalence of high levels of TC and LDL-C during 2013 to 2015 increased dramatically by 2 to 4 times in comparison with that in 2010.
A study was conducted in 2012 among 16,434 children and adolescents aged 6 to 17 years in China. The prevalence of high TC, high LDL-C, low HDL-C, high TG, and dyslipidemia was 5.4%, 3.0%, 13.5%, 15.7%, and 28.5%, respectively. Intake of sugary drinks more than once per week, being sedentary >10 hours per day, overweight, and obesity might be the risk factors of dyslipidemia among children and adolescents.
A national survey examined 16,100 children aged 6 to 17 years in 2013. After adjustment for covariates, only-child status was associated with an increased risk of a high level of LDL-C.
The awareness, treatment, and control rates of dyslipidemia among Chinese adults were low [Figure 4]. The China National Diabetes and Metabolic Disorders Study (CNDMDS) was conducted from 2007 to 2008. The proportions of awareness, treatment, and control of a high TC level (≥6.22 mmol/L) were 24.15%, 17.7%, and 14.75%, respectively, among Chinese adults aged ≥20 years. CCDRFS 2010 demonstrated that the awareness, treatment, and control rates of dyslipidemia (defined as TC ≥6.22 mmol/L, or TG ≥2.26 mmol/L, HDL-C <1.04 mmol/L, or LDL-C ≥4.14 mmol/L) were comparatively low among Chinese adults aged ≥18 years. CHS 2012 to 2015 indicated that the awareness, treatment, and control rates of dyslipidemia were 16.1%, 7.8%, and 4.0%, respectively, among participants aged ≥35 years.
In the fourth CCDRFS 2013 to 2014, 10-year risks for atherosclerotic cardiovascular diseases (ASCVDs) in individuals were assessed using the risk-evaluation plan recommended by the 2016 Chinese Guideline for the Management of Dyslipidemia in Adults. Among Chinese adults aged ≥18 years, 1.8% (2945 participants) had a very high risk for ASCVDs and 9.4% (15,382 participants) had a high risk to develop ASCVDs. Among individuals with a high risk for ASCVDs, only 5.5% were treated and 25.5% of them had controlled LDL-C levels (<2.6 mmol/L). For individuals with a very high risk, 14.5% were treated and 6.8% of them achieved their LDL-C goals (<1.8 mmol/L). The treatment rates in rural residents who had high LDL-C levels were even lower: 4.6% for those with a high risk and 11.5% for those with a very high risk of ASCVDs.
The Dyslipidemia International Study-China included 25,317 patients with dyslipidemia. They were aged ≥45 years and received lipid-lowering therapy for at least 3 months. The compliance rate of LDL-C for patients with a high and very high risk of ASCVDs was 41.1% and 26.9%, respectively.
Data from Global Burden of Diseases 2017 showed that a high LDL-C level was the third major risk factor for CVD in China (next to hypertension and a high-sodium diet). A prospective cohort study included 51,407 participants from the Kailuan group and were followed up for an average of 6.84 years. Cumulative exposure to a high LDL-C level (≥3.4 mmol/L), including the years and values calculated by repeated measurements, was a risk factor for new-onset acute MI, indicating a “cumulative exposure” hazard of LDL-C to cardiovascular health.
A prediction was made by analyzing the data from CHNS 2009. Universal treatment of dyslipidemia with lipid-lowering therapies could avert 9.72 million acute MIs, 7.82 million strokes, and 3.36 million CVD deaths during the 2016 to 2030 period.
Serveral surveys on the prevalence of DM were conducted in China from 1980 to 2017 [Figure 5]. A cross-sectional study was conducted among 75,880 participants aged ≥18 years from 31 provinces in mainland China from 2015 to 2017. The weighted prevalence of total DM, self-reported DM, newly diagnosed DM, and pre-DM diagnosed by American Diabetes Association criteria was 12.8%, 6.0%, 6.8%, and 35.2%, respectively. The total number of patients with DM in mainland China is estimated to be 129.8 million (70.4 million men and 59.4 million women). The weighted prevalence of DM in China using the WHO criteria was 11.2%.
Based on the Diabetes Surveillance System of Zhejiang Province, 879,769 newly diagnosed T2DM patients aged ≥20 years were identified. The age-standardized overall incidence rate of T2DM was reported to be 281.73 (95% CI: 281.26–282.20) per 100,000 person-years. The standardized annual incidence rate increased from 164.85 in 2007 to 268.65 per 100,000 person-years in 2017, with an average annual increase of 4.01%, and grew more rapidly in male, younger, and rural populations.
A nationally representative cross-sectional survey was conducted in 2013. It consisted of 170,287 participants aged ≥18 years from 31 provinces, autonomous regions, and municipalities in mainland China. The estimated standardized prevalence of total diagnosed and undiagnosed DM was 10.9% (95% CI: 10.4%–11.5%), and that of pre-DM was 35.7% (95% CI: 34.1%–37.4%). With approximately 1.09 billion adults in total in mainland China, it was projected that 388.1 million Chinese adults might have pre-DM. Overall, 47% of the Chinese adult population was estimated to have DM or pre-DM, slightly lower than the 49% to 52% estimate in the USA population. Among persons with DM, 36.5% (95% CI: 34.3%–38.6%) were aware of their diagnosis and 32.2% (95% CI 30.1%–34.2%) were treated; 49.2% (95% CI: 46.9%–51.5%) of patients treated had adequate glycemic control.
The CKB study indicated that DM was associated with increased mortality from IHD (RR = 2.40; 95% CI: 2.19–2.63) and stroke (RR = 1.98; 95% CI: 1.81–2.17). It was estimated that a median of 9 years of life would be lost for individuals with DM diagnosed at the age of 50 years.
The Da Qing Diabetes Prevention Study was conducted among adults with impaired glucose tolerance. During 30-year follow-up, compared with control, the participants in the combined-intervention group had a median delay in DM onset of 3.96 years, and an average increase in life expectancy of 1.44 years. The cumulative incidence of DM, cardiovascular events, and cardiovascular deaths was reduced by 39%, 26%, and 33%, respectively.
According to an analysis using a mathematical model, lifestyle intervention was a cost-effective alternative for people with pre-DM to reduce the disease burden related to T2DM in China. In comparison with no prevention, the lifestyle intervention reduced the cumulative probabilities of T2DM by 9.53%, which resulted in average additional benefits in life expectancy and QALY of 0.82 years and 0.52 QALYs, respectively, and saved total average costs of $700 over a lifetime period. The incremental cost-effectiveness ratio between lifestyle intervention and no intervention was −1339$ per QALY gained.
Chronic kidney disease (CKD)
A national cross-sectional survey was conducted between 2009 and 2010 among 47,204 adults aged ≥18 years from 13 provinces in China to measure CKD prevalence. The adjusted prevalence of estimated glomerular filtration rate <60 mL/min per 1.73 m² was 1.7%, and that of albuminuria (defined as a urinary albumin: creatinine ratio >30 mg/g) was 9.4%. The overall prevalence of CKD was 10.8%, so the number of patients with CKD in China (HCM) was estimated to be about 119.5 million.
According to the China Kidney Disease Network (CK-NET) 2016 Annual Data Report, the total medical expenditure of all inpatients with CKD included in the analysis for 2016 was 27,646 million CNY, accounting for 6.50% of the overall expenditure in the database; however, the percentage of inpatients with CKD was only 4.86%. The median cost per inpatient with CKD was 15,405 CNY. The median annual cost per patient receiving dialysis in 2016 was 89,257 CNY for hemodialysis and 79,563 CNY for peritoneal dialysis, which increased compared with that in 2015.
A total of 98,042 participants aged ≥18 years were included in the analysis from the China National Nutrition and Health Survey 2010 to 2012. Metabolic syndrome was defined according to US National Cholesterol Education Program Adult Treatment Panel III criteria. The overall standardized prevalence of metabolic syndrome was 24.2%. Analysis of the data from 16,872 adolescents aged 10 to 17 years in mainland China indicated that the weighted prevalence of metabolic syndrome was 2.4% based on China criterion (defined by Chinese Pediatric Society within the Chinese Medical Association) but was 4.3% based on the Cook criterion.
A meta-analysis included 115,988 participants aged 28 to 49.4 (median, 43.7) years. The pooled prevalence of insomnia was 15.0% in China. Another meta-analysis revealed that the pooled prevalence of sleep disturbances was 35.9% in older Chinese adults.
The CKB study found that 11.3% of participants reported having the symptom of difficulties in initiating or maintaining sleep, 10.4% reported having early-morning awakening, and 2.2% reported having daytime dysfunction, for at least 3 days/week. Cox regression analysis showed that these 3 insomnia symptoms were associated with an increased risk of total CVD, with respective adjusted HRs of 1.09 (95% CI: 1.07–1.11), 1.07 (95% CI: 1.05–1.09), and 1.13 (95% CI: 1.09–1.18). Difficulties in initiating or maintaining sleep was associated with a higher risk of acute MI.
A cross-sectional study conducted among 8371 Chinese adults demonstrated that individuals with insomnia had an increased risk of atrial fibrillation (AF) compared with those not suffering from insomnia (OR = 1.92, 95% CI: 1.00–3.70), and a positive relationship between insomnia and AF was more remarkable in those aged <40 years (OR = 6.52, 95% CI: 1.64–25.83).
Fourteen epidemiological studies, which were conducted with the same research method and diagnostic criteria for obstructive sleep apnea hypopnea syndrome in China from 2000 to 2017, were reviewed systematically. The total prevalence of adult obstructive sleep apnea hypopnea syndrome was 3.93% (95% CI: 3.14%–4.73%). Subgroup analysis showed that it was 5.19% (95% CI: 4.14%–7.23%) for men and 2.17% (95% CI: 1.00%–3.34%) for women.
Ambient air pollution ranked fourth and household air pollution ranked fifth in terms of the age-standardized disability-adjusted life-year rate in China. The total deaths and age-standardized disability-adjusted life-year rate attributable to solid-fuel household pollution decreased by 24.5% and 42.4%, respectively, from 1990 to 2013 in China.
In 2019, ambient air quality met the targets in 157 out of 337 (46.6%) cities in China. In comparison with the data in 2018, the concentrations of 5 air pollutants (particulate matter (PM)2.5, PM10, sulfur dioxide (SO2), nitric dioxide (NO2), and carbon monoxide (CO)) were on the decline or unchanged, whereas that of ozone (O3) increased. PM2.5 accounted for 78.8% of the days with heavy and severe pollution as the major pollutant.
Across the adult population in China, long-term exposures to PM2.5 accounted for 30.8 million premature deaths between 2000 and 2016, with an annual burden ranging from 1.5 to 2.2 million.
A prospective cohort study enrolled 226,186 participants living in urban areas of China. Compared with persistent users of clean fuel, persistent users of solid fuel had an increased risk of all-cause mortality (HR = 1.19, 95% CI: 1.10–1.28), cardiovascular mortality (HR = 1.24, 95% CI: 1.10–1.39), and respiratory mortality (HR = 1.43, 95% CI: 1.10–1.85). Risks of all-cause and cardiopulmonary mortality decreased when switching from use of solid fuels to clean fuels for cooking.
Air-pollutant concentrations in 338 cities in 2017 were used to estimate the air pollution-related health burden in China. The economic loss of overall health burden (premature mortality and hospital admissions) attributable to short-term exposure to air pollutants (PM2.5, PM10, SO2, NO2, CO, and O3) was 2065.54 billion CNY in China, which was equivalent to 2.5% of the national gross domestic product in 2017.
Community-based prevention and treatment of CVDs
Since 2010, the Chinese Center for Disease Control and Prevention has organized and carried out construction of national demonstration areas (whole counties or districts) for the comprehensive prevention and control of chronic diseases. As of 2020, 488 national demonstration areas had been established, covering 17.1% of all counties and districts. Construction of national demonstration areas promoted cooperation between the government and society for CVD prevention, and changed the priority from a high-risk strategy to a population-wide strategy for primary prevention of CVD. The risk factors for CVD, including current smoking, overweight and obesity, physical inactivity, hypertension, and the like, had been controlled in some national demonstration areas.
Results from a hypertension-management program indicated that a multicomponent-intervention strategy that combined workplace health promotion and management of hypertension with an intervention at a community health center could be an effective approach for hypertension control among the Chinese working population. Employees in the intervention group were invited to participate in a “workplace wellness program,” a guidelines-oriented hypertension-management protocol, and an intervention at a community health center accompanied by monthly visits for achieving BP control over a period of 24 months. BP levels and hypertension control were improved significantly among employees with hypertension in the intervention group. This intervention strategy may be considered in other types of workplaces for hypertension management.
Prevalence and mortality
The prevalence of CVD in China is on the rise. The number of patients with CVD is estimated to be 330 million, including 13 million strokes, 11.39 million CHDs, 5 million pulmonary heart diseases, 8.9 million heart failures (HF), 4.87 million AF, 2.5 million rheumatic heart diseases, 2 million congenital cardiovascular defects (CCD), 45.3 million lower-extremity arterial diseases, and 245 million hypertension.
The mortality associated with CVDs ranked first in 2018, above that of cancer and other diseases. The mortality of CVDs in rural areas had exceeded that in urban areas and continued to be higher since 2009 [Figure 6]. In 2018, the mortality of CVDs in rural areas was 322.31 per 100,000 [Figure 7], 162.12 per 100,000 for heart diseases, and 160.19 per 100,000 for cerebrovascular diseases. The mortality of CVDs in urban areas was 275.22 per 100,000 [Figure 8], 146.34 per 100,000 for heart diseases, and 128.88 per 100,000 for cerebrovascular diseases.
CVD is the first cause of death among urban and rural residents [Figure 9]. In 2018, CVDs accounted for 46.66% and 43.81% of total deaths in rural and urban areas, respectively. Two out of five deaths were attributable to CVDs.
According to the China Health Statistics Yearbook 2019, the mortality of CHD had been on the rise since 2012. It was higher among rural residents (128.24 per 100,000) than among urban residents (120.18 per 100,000) and higher among men than among women in 2018. The mortality of CHD in rural areas increased significantly and exceeded that in urban areas by 2016 [Figure 10].
According to the 5th National Health Services Survey in China 2013, the prevalence of CHD was 10.2‰ among residents aged ≥15 years, 12.3‰ in urban areas, and 8.1‰ in rural areas. It was 27.8‰ for those aged ≥60 years. Based on these estimates and on the data from the 6th Nationwide Population Census in 2010, it was estimated that there would be 11.396 million patients with CHD among residents aged ≥15 years in mainland China. This number was 1.08-million greater than that of patients with CHD across all ages in 2008, which was calculated using the data from the 4th National Health Services Survey.
The mortality of acute MI showed a rising trend from 2002 to 2018 [Figure 11]. It increased rapidly since 2005. The mortality of acute MI in rural areas had been higher than that in urban areas in 2007, 2009, and 2011. It started to accelerate sharply in 2012, and exceeded that in urban areas since 2013.
The China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE)-Retrospective Acute Myocardial Infarction (AMI) Study selected 162 hospitals in China by random sampling to create a sample of 13,815 patients admitted to hospital for ST-segment elevation myocardial infarction (STEMI), and 11,986 (86.76%) were included in analysis of in-hospital outcomes. Between 2001 and 2011, estimated national rates of hospital admission for STEMI per 100,000 people increased by 3.27 times.
The China Acute Myocardial Infarction Registry examined variations in the care and outcomes of patients with STEMI directly admitted to province-, prefecture-, or county-level hospitals between 2013 and 2014. Overall, 72.0% of patients arrived at the hospital within 12 hours after symptom onset, and 14.1% of patients used ambulances. The rate of perfusion therapy for all patients was 57.5%; it was 69.4%, 54.3%, and 45.8% in province-, prefecture-, and county-level hospitals, respectively. The reasons for not receiving reperfusion therapy included patients or family members refusing because of concerns about reperfusion-related complications, patient’s finances, physician’s decision, and an unclear diagnosis. The in-hospital delay of reperfusion therapy remained obvious, with only approximately one-third reaching the time goals. There was a significant and progressive trend for higher in-hospital mortality among 3 levels of hospitals (3.1% at province level, 5.3% at prefecture level, and 10.2% at county level).
A cross-sectional study analyzed the medical records in 153 randomly selected hospitals in 2001, 2006, 2011, and 2015 across China. There was a borderline difference across regions for in-hospital mortality among patients with acute MI. In comparison with the data in 2001 to 2006, the in-hospital mortality in 2011 to 2015 decreased across western, central, and eastern China. There was a significant difference across regions in the process of care. The geographic variation in mortality did not change over time.
According to an analysis of 16,100 medical records of patients with acute MI in China from 2001 to 2011, most patients upon hospital discharge did not receive any of the 5 instructions on diet, exercise, bodyweight control, blood lipid evaluation, and smoking cessation. In 2011, more than 50% of the patients did not receive any instructions, 2.7% received 3 to 5 instructions, and less than 40% received a consultation on diet. The rate of bodyweight control was only 1.3% in patients with BMI ≥24 kg/m2, which showed little change within 10 years.
The China PEACE-Prospective AMI Study approached 3387 consecutive patients with acute MI hospitalized within 24 hours of symptom onset from 53 geographically diverse hospitals in China. Unplanned 30-day readmission occurred in 6.3% of the cohort, and nearly half occurred within 5 days of discharge. Overall, 77.7% of all-cause unplanned readmissions within 30 days of discharge were for cardiovascular diagnoses; among these, angina (31.2%), HF (16.7%), and acute MI (13.0%) were the most common. The observed rate of 1-year recurrence for acute MI was 2.5%, with 35.7% events occurring within the first 30 days. Among patients who died at 1-year follow-up, 28.4% had experienced recurrent acute MI. Among patients experiencing recurrent acute MI, 32.1% died during 1-year follow-up.
The Clinical Pathways for Acute Coronary Syndromes study analyzed the data of patients with acute coronary syndrome recruited in 70 hospitals from 17 provinces in China. Of the 15,140 patients included in the study, 12,094 had follow-up data at 12 months, and 5612 completed 24-month follow-up by study cessation. The use of indicated cardiovascular-prevention treatment declined steadily over time following acute coronary syndrome. Upon hospital discharge, 86.1% were on a combination of antiplatelet, statin, and BP-lowering drugs. Use of this combination fell to 68.0% at 12 months and 59.7% in patients followed to 24 months. Patients admitted to tertiary hospitals were more likely to be on this combination compared with secondary hospitals (upon hospital discharge, 90.1% vs. 79.5%; at 12 months 71% vs. 64%).
According to the data of percutaneous coronary intervention (PCI) in mainland China from the Direct Network Reporting System, the total number of PCIs was 915,256 in 2018, which meant a prevalence of 651 PCIs per million residents and an average number of 1.46 stents per patient with CHD. The mortality of PCI was 0.26%, and 45.9% deaths occurred during emergency interventions.
Between 2004 and 2013, for patients receiving isolated coronary artery bypass grafting (CABG) in urban teaching hospitals in China, the in-hospital total mortality rate decreased from 2.8% to 1.6%, with a fall of 42.9%, and 7-day in-hospital mortality rate decreased from 1.5% to 0.8%. The rate of major complications decreased from 7.8% to 3.8%. Between 2004 and 2013, the median postoperative length of stay (LOS) declined from 12.0 to 10.0 days, and total LOS declined from 22.0 to 20.0 days. The proportion of patients who had an overall LOS for more than 30 days declined markedly from 24.8% to 17.4%.
A multicenter cross-sectional study assessed the appropriateness of coronary revascularization in 5875 stable CHD with coronary lesion stenosis ≥50% in 4 heart centers in China. According to Chinese appropriate-use criteria for coronary revascularization, decision-making for 18.1% of patients was classified as “inappropriate.” Among 3452 patients undergoing PCI, decision-making for 20.9% of patients was classified as “inappropriate,” for 51.1% of patients was classified as “uncertain,” and for 28.0% of patients was classified as “appropriate.” Among 2047 patients receiving medical therapy, decision-making for 16.0% of patients was classified as “inappropriate.” Among 376 patients undergoing CABG, decision-making for 3.5% of patients was classified as “inappropriate.” This study indicated that decision-making for CABG was mostly appropriate.
The mortality rate for cerebrovascular disease in China was 149.49 per 100,000 in 2018, accounting for 22.33% of all deaths, and ranked third among all causes of death. It was higher in rural areas (160.19 per 100,000) than in cities (128.88 per 100,000), and higher in men (164.31 per 100,000) than in women (134.15 per 100,000). The annual crude mortality of cerebrovascular disease in rural areas was higher than that in urban areas from 2003 to 2018 [Figure 12].
In 2013, a nationally representative, door-to-door epidemiological survey on transient ischemic attack (TIA) in China was conducted among participants from 178,059 families at 155 disease-surveillance points using a complex, multistage, probability sampling design. The weighted incidence of TIA was 23.9 per 100,000 in the population. It was estimated that there were 1.35 million TIA patients nationwide, with 0.31 million new cases of TIA annually in China.
The China Stroke Prevention Project was conducted to investigate the prevalence and risk factors of stroke in a nationally representative sample of 207,323 individuals aged ≥40 years within 76 residential communities from 31 provinces in 2013. The age-standardized prevalence of stroke was estimated to be 2.08%, 2.38% in men and 1.82% in women, 1.90% in urban regions and 2.29% in rural areas.
Data from the Hospital Quality Monitoring System (HQMS) showed that 3,010,204 in-patients with stroke were admitted to 1853 tertiary hospitals during 2018. Of those, 81.9% were ISs, 14.9% were intracerebral hemorrhages (ICHs), and 3.2% were subarachnoid hemorrhages (SAHs). Tibet had the highest proportion of ICH (61.3%), followed by Qinghai (44.2%), and Guizhou (34.9%). Hainan had the highest proportion of IS (81.0%), followed by Heilongjiang (79.4%) and Liaoning (75.6%).
The CKB study analyzed the data of 45,732 participants who survived stroke at 28 days. Among them, 41% had recurrent stroke at 5 years (IS = 41%, ICH = 44%, SAH = 22%, and unspecified stroke type = 40%). After IS had occurred, 91% of recurrent strokes were also IS. After ICH, 56% of recurrent strokes were ICH, and 41% were IS.
The results of the CKB study demonstrated that plasma concentrations of LDL-C were positively associated with a risk of IS and inversely associated with a risk of ICH. Throughout the range of 1.7 to 3.2 mmol/L, each 1 mmol/L higher-than-usual LDL-C was associated with a 17% (RR = 1.17, 95% CI: 1.10–1.25) higher risk of IS, and a 14% (RR = 0.86, 95% CI: 0.80–0.92) lower risk of ICH. Each 0.3 mmol/L higher-than-usual HDL-C was associated with a 7% (RR = 0.93, 95% CI: 0.89–0.97) lower risk of IS, but not with ICH. The associations of levels of LDL-C and HDL-C with IS were independent of each other.
From 2014 to 2018, 43,359 (1.7%) of 2,613,035 participants aged 35 to 75 years from 31 provinces in China reported a history of IS, among whom the rate of use of antiplatelet drugs or statins was only 29.0%.
Data of 560,447 patients with IS from June 2015 to June 2018 indicated that only 69,841 (12.5%) were transported by emergency medical service. Compared with self-transport, transport by emergency medical service was associated with significantly shorter onset-to-door time, door-to-needle time, earlier arrival, and more rapid treatment.
Key performance indicators were assessed among 269,428 patients with IS from 31 provinces in China based on national guidelines using data from the Chinese Stroke Center Alliance in 2018. Intravenous recombinant tissue plasminogen activator was administered in 16,270 (24.2%) out of 67,122 eligible patients who arrived within 3.5 hours after initial symptom onset and were treated within 4.5 hours, and the in-hospital death rate was 0.4%.
Disorders of heart rhythm
According to CHS 2012–2015, the weighted prevalence of AF was 0.71% in the Chinese population aged ≥35 years. It was higher in rural areas (0.75%) than in urban ones (0.63%). Thirty-four percent of patients were diagnosed as AF for the first time and were not aware of their condition. The AF prevalence was 2.35% in participants aged ≥75 years.
The overall prevalence of stroke in Chinese patients with AF was 24.81%. It was 26.88% in those with rheumatic valvular AF, and 24.15% in those with nonvalvular AF. In patients with nonvalvular AF, age ≥75, history of hypertension, DM, and left-atrial thrombi were independently associated with stroke.
The Chinese Atrial Fibrillation Registry study assessed 7977 patients with nonvalvular AF in 32 hospitals from 2011 to 2014. Significant improvements in oral-anticoagulation treatment were observed in Chinese patients with AF. The proportion of oral-anticoagulation use was 36.5%, 28.5%, and 21.4% for patients with a CHA2DS2-VASc score ≥2, 1, and 0, respectively. Rates of oral-anticoagulation use varied widely among different hospitals. It varied from 9.6% to 68.4% in tertiary hospitals and from 4.0% to 28.2% among nontertiary hospitals.
According to data from a national AF registration platform, the proportion of radiofrequency catheter ablation (RFCA) procedures for AF treatment increased annually in China, accounting for 23.1%, 27.3%, and 31.9% of total ablations in 2016, 2017, and 2018, respectively. Isolation of the circumferential pulmonary vein remained one of the main procedures, accounting for 60.2% of total ablations. The incidence of procedure-related cerebrovascular complications following AF ablation was 0.36% per procedure for IS and 0.1% per procedure for ICH.
Between July 2005 and June 2006, 678,718 subjects were monitored in a prospective study. During the study period, a total of 284 sudden cardiac deaths (SCDs) occurred, and accounted for 9.5% of overall mortality. The overall incidence of SCD was 41.8 of 100,000 per year, which was higher for men (44.6 of 100,000 per year) than for women (39.0 of 100,000 per year). It was estimated that the approximate annual incidence of SCD among Chinese citizens was about 500,000.
According to data from the online registration system of the National Health Commission of the People’s Republic of China (China NHC), the number of pacemaker implantations in 2019 increased by 9.3% compared with that in 2018. With regard to indications, sick sinus syndrome, atrioventricular block, and others accounted for 50.08%, 43.52%, and 6.4%, respectively. Double-chamber pacemakers accounted for nearly 70% of implantations.
Follow-up of 2125 patients with cardiovascular implantable electrical device (CIED) revealed that 34 patients were diagnosed with CIED infection in the first year after implantation. The risk factors of infection by the CIED include BMI increase, accepting anticoagulant drugs, and longer than 4 days of hospital stay.
According to data from the online registration system of China NHC, the number of RFCA procedures has been growing rapidly since 2010, with an annual growth of 13.2% to 17.5%. Of all indications for RFCA in 2019, paroxysmal supraventricular tachycardia accounted for 42%, AF for 33%, ventricular premature beat and ventricular tachycardia for 17%, atrial flutter for 4%, and atrial premature beat and atrial tachycardia for 4%. The number of RFCA procedures in 2019 decreased compared with that in 2018.
According to data from the online registration system of China NHC, the number of implantable cardioverter defibrillators (ICDs) implanted in 2019 kept on a rise, and 5031 patients accepted ICD implantation. Of all ICDs, 62% were single-chamber and 38% were dual-chamber, 55% were used for secondary prevention and 45% for primary prevention. A prospective registration analysis was performed in 440 patients with an implanted ICD from 2013 to 2015 in 20 hospitals. Analysis showed that 75% of patients met class-I indications, indicating that the ICD indications were followed appropriately in China.
In 1999, biventricular pacing was started for treatment of HF. According to data from the online registration system of China NHC (excluding military hospitals), the number of cardiac resynchronization therapy (CRT) procedures in 2019 increased by 2.05% compared with that in 2018. Because patients with HF meeting the criteria for a CRT pacemaker (CRT-P) could also receive a CRT defibrillator (CRT-D), the proportion of CRT-D procedures increased annually, and had increased to 64% by 2019. Results of 454 HF patients who received a CRT-P or CRT-D in 22 hospitals between 2013 and 2015 showed that 52.2% of them received CRT-D implantation.
Valvular heart diseases
The China Elderly Valvular Disease study was conducted among 8638 patients aged ≥60 years with at least moderate valvular heart diseases by echocardiography in 69 hospitals from September to December 2016. Rheumatic causes stayed significant for mitral stenosis, but a growing predominance of degenerative causes was detected in patients with an aortic stenosis or aortic regurgitation. Notably, the proportion of ischemic causes in men with mitral regurgitation was slightly higher than degenerative causes whereas, in women, degenerative causes were the primary etiology.
In a retrospective study, 14,322 patients who underwent heart-valve surgery at 5 cardiac surgical centers in mainland China from 2008 to 2012 were included. Rheumatic valve disease accounted for 63.1% of all causes of heart-valve disease for patients undergoing valve procedures. Patients undergoing multiple valve (MUV) procedures more often had functional tricuspid valve disease than those undergoing single-valve procedures (47.6% vs. 7.8%). Valve replacement was the key treatment for valve procedures. Mitral valve repair was performed in more than 30% of patients undergoing a single mitral valve procedures for mitral regurgitation. Tricuspid valve repair was performed in more than 95% of patients undergoing MUV procedures who had functional tricuspid valve disease, compared with nearly 50% of patients undergoing single tricuspid valve procedures. Moreover, patients undergoing MUV procedures were more likely to have concomitant AF ablation procedures (9.8% vs. 6.5%), whereas they had a lower incidence of CABG than those undergoing single-valve procedures (2.4% vs. 6.6%).
According to statistics from the Extracorporeal Circulation Group of Chinese Society of Biomedical Engineering, about 80,000 valve procedures were performed in China each year. Data from the China Cardiac Surgery Registry indicated that the number of valve procedures had been on a downward trajectory from 2014 to 2018, with a decline of 23.62% from 2014 to 2017. However, a slight rise was present in 2018 compared with 2017.
CCDs are the major congenital anomalies in China, and rank first among all birth defects in many geographical regions. A multicenter prospective screening study was conducted between August 2011 and November 2012 among 122,765 consecutive infants born at 12 hospitals in the eastern region and 6 hospitals in the western region in China. The overall prevalence of CCDs was 8.98 per 1000 live births, which was higher in female infants (11.11 per 1000) than in male infants (7.15 per 1000).
According to China Health Statistics Yearbook 2019, the mortality of CCDs among urban residents in China was 0.84 per 100,000 in 2018. It was 1.02 per 100,000 in rural areas, higher than that in cities.
In 2019, 81,246 patients with CCDs underwent cardiac surgery in 724 hospitals in China, accounting for 32% of all the cardiac and aortic operations. Although CCDs still ranked first among all the defects to be treated by cardiac surgery, the proportion was on the decline. In 2019, 54,908 patients aged <18 years with CCDs underwent cardiac surgery, accounting for 66.6% of all cases of CCDs undergoing cardiac surgery, which suggested that a considerable proportion of adult patients with CCDs were treated by cardiac surgery.
Based on data from the Direct Reporting Network System of China NHC and that of the military counterpart, the total number of interventional procedures in 2019 for CCDs was 39,027 in China, which increased by 6.32% compared with that in 2018. Atrial septal defect, patent ductus arteriosus, patent foramen ovale, ventricular septal defect, and pulmonary stenosis were the top-five CCDs to be treated by interventional procedures. The number of cases of patent foramen ovale increased by 73.77% compared with that in 2018. In 2019, 483 interventional cardiologists in 313 local hospitals were able to carry out interventional procedures for CCDs, and 34,758 interventional procedures were performed in local hospitals, an increase of 5.45% compared with that in 2018. The success rate was 98.41%, the incidence of serious complications was 0.12%, and mortality was 0.01%.
Cardiomyopathy and HF
An epidemiologic investigation was performed in 8080 adults from 9 provinces in China from October 2001 to February 2002 using a multistage, random-sample design. The prevalence of hypertrophic cardiomyopathy (HCM) was estimated to be about 0.16%. It was higher in men (0.22%) than in women (0.10%). The age- and sex-adjusted prevalence was about 80 per 100,000 adults. Based on the estimated prevalence, there are at least 1 million cases in China.
HCM is the most common cause of SCD in patients aged under 35 years. A total of 529 unrelated HCM patients were recruited prospectively at Beijing Fuwai Hospital and followed for (4.7 ± 3.2) years between 1999 and 2010. The incidence of cardiovascular death was 1.7%.
A survey was conducted from July to December 2011 among 49,751 permanent residents from 120 villages in 7 provinces in northern non-endemic areas with Keshan disease in China. Six cases of dilated cardiomyopathy (DCM) were detected, and the prevalence was 1.2 per 10 000.
Data of 10,714 patients with HF from 42 hospitals in China in 1980, 1990, and 2000 were analyzed by the Society of Cardiology, Chinese Medical Association. The proportion of DCM in the 3 years was 6.4%, 7.4%, and 7.6%, respectively. Data were collected prospectively on 13,687 patients with a primary diagnosis upon hospital discharge of HF who were enrolled from 132 participating hospitals between 2012 and 2015 in the China HF registry study. DCM accounted for 16.0% of all comorbidities.
Genetic testing was performed in 529 unrelated HCM patients in China. Rare variants were identified in 43.9% of study patients, predominantly located in MYH7 and MYBPC3.
A homozygous founder variant of desmoglein-2, p.Phe531Cys, was identified recently to be associated with arrhythmogenic right-ventricular cardiomyopathy (ARVC), and had a surprisingly high frequency of 8.47% among Chinese ARVC patients with a full penetrance. A few genetic variants have been uncovered to be associated with DCM. An early survey in China revealed that the prevalence of familial DCM was 8.8% among the probands with DCM.
A prospective registration analysis was performed in 440 patients with an implanted ICD from May 2013 to November 2015 in 20 hospitals. Among the underlying heart diseases, HCM, DCM, and ARVC accounted for 7.0%, 16.6%, and 3.9%, respectively.
The proportion of primary cardiomyopathy among all the indications for heart transplantation in China was 73.9% in adult patients and 83.7% in children.
Data from 22,158 participants were analyzed in CHS 2012–2015. The prevalence of HF was 1.3% (estimated 13.7 million) in Chinese adults aged ≥35 years, suggesting that the overall prevalence of HF increased by 44% in comparison with that in 2000.
Data were collected prospectively on 13,687 patients with a primary diagnosis upon hospital discharge of HF who were enrolled from 132 participating hospitals between January 2012 and September 2015 in the China HF registry study. The in-hospital mortality was 4.1%. Common comorbidities included hypertension (50.9%), CHD (49.6%), and AF (24.4%). Infection was the leading precipitating factor for HF aggravation, followed by ischemia and exertion.
Data on pharmaceutical therapy of HF were taken from some hospitals in China. All patients were admitted to hospital in 1980, 1990, 2000, and 2012–2015. The proportion of patients receiving diuretics did not change much, whereas the proportion of users of angiotensin II receptor antagonists, aldosterone receptor antagonists, and β-blockers increased significantly.
Up to now, the State Food and Drug Administration in China has approved only 2 registered clinical trials to evaluate the safety and efficacy of ventricular assist devices (VADs) for end-stage HF, both of which were sponsored by Fuwai Hospital. The first clinical trial was on EVAHEART I (a VAD manufactured by Chongqing Yongrenxin). From January 2018 to December 2019, 15 devices had been implanted. No death occurred during the perioperative period. Long-term follow-up revealed that except 1 patient underwent heart transplantation 156 days after implantation of EVAHEART I, the other 14 patients survived 350 to 728 days. The second clinical trial was on CH-VAD (a VAD manufactured by Suzhou Tongxin). From January to December 2019, 23 devices had been implanted in 3 centers. One patient died during the perioperative period. As for the other 22 patients, their cardiac function recovered to New York Heart Association (NYHA) class I–II at 1 month after the procedure, and they had long-term survival of 60 to 356 days. Compared with data published by the International Society for Mechanical Circulatory Support during the same period, the 30-day perioperative mortality of 37 patients implanted with a VAD in domestic centers was 0, and the 1-year survival was 92%, which reached the international standard.
According to data from the China Heart Transplant Registry system, by the end of 2019, 57 centers in China had been qualified for heart transplantation. From 2015 to 2019, a total of 2262 heart-transplantation procedures had been performed and registered in the centers of mainland China, with 279 procedures in 2015, 368 in 2016, 446 in 2017, 490 in 2018, and 679 in 2019. The proportion of non-ischemic cardiomyopathy among the indications for heart transplantation was 71.0% for all recipients and 76.4% for pediatric recipients. In 2019, the in-hospital survival rate of heart-transplant recipients was 93.2% in China. Multiple-organ dysfunction syndrome and primary graft failure accounted for more than 50% of the causes of early death. The average postoperative survival rate from 2015 to 2019 was 85.2% at 1 year and 80.0% at 3 years for heart-transplant recipients in China.
Pulmonary vascular and venous thromboembolic diseases
A prospective cross-sectional study of 1934 patients with systemic lupus erythematosus (SLE) was conducted using the Chinese SLE Treatment and Research registry from 2009 to 2010. Resting transthoracic echocardiography was used to estimate pulmonary artery pressure. Pulmonary arterial hypertension (PAH) was defined as systolic pulmonary artery pressure ≥40 mmHg. Results were published in 2014 and showed that PAH prevalence was 3.8% in Chinese patients with SLE.
New PAH-specific drugs were not available in China before 2006. The survival rate of idiopathic PAH and familial PAH in Chinese patients at 1, 3, and 5 years was 68.0%, 38.9%, and 20.8%, respectively. Survival estimates at 1 year and 3 years increased to 92.1% and 75.1%, respectively, in the modern treatment era.
Between 1997 and 2008, consecutive patients admitted to the inpatient ward with a diagnosis of suspected pulmonary embolism (PE) were registered from 60 hospitals in China. A total of 18,206 patients were confirmed to have PE from 16,972,182 hospital admissions. The annual incidence was 0.1%.
During January 2007 to December 2016, 105,723 patients with venous thromboembolism (VTE) were identified in 90 hospitals across mainland China, 43,589 patients with PE (with or without deep venous thrombosis), and 62,134 patients with deep venous thrombosis alone. For patients with VTE, the age- and sex-adjusted hospitalization rate increased from 3.2 to 17.5 per 100,000 population and in-hospital mortality decreased from 4.7% to 2.1%. The mean LOS declined from 14 days to 11 days.
A total of 13,609 patients admitted (≥72 h) to 60 urban, tertiary Chinese hospitals due to acute medical conditions or surgery from March to September 2016 were assessed for VTE risk. Major risk factors in surgical and medical patients were major open surgery (52.6%) and acute infection (42.2%), respectively. The overall rate of any prophylaxis and appropriate prophylactic method based on American College of Chest Physicians guidelines, 9th edition was 14.3% and 10.3% in surgical and medical patients, respectively.
Efficacy, safety, and outcomes were evaluated retrospectively in 1200 patients who received permanent vena-cava filters to prevent PE at 3 medical centers in China from January 2002 to January 2013. Filters were placed via the femoral or jugular vein, with 62 placements at the superior vena cava and 1138 at the inferior vena cava. The patency rate of the vena cava was 90% at 5 years. The mortality was 0.5% during 30 days post-filter placement. After 30 days, the mortality rate was 2.4%. No PE reoccurred, and there were no other clinical adverse events.
Aortic and peripheral arterial diseases
According to China Health Insurance Research Data 2011, the estimated annual incidence of acute aortic dissection (AAD) was 2.8 per 100,000 in China. The mean age was 58.9 years, which was younger than that (63.1 years) of patients enrolled in International Registry of Acute Aortic Dissection (IRAD).
According to the Registry of Aortic Dissection in China (Sino-RAD), the mean age of patients with AAD was 58.9 years, which was about 10 years younger than that in Western populations. A retrospective analysis indicated that compared with the participants in IRAD, patients with acute type-A aortic dissection (AAD) in China were more likely to have hypertension due to a high-salt diet, low education, and lack of routine physical examination. For type-A AAD, 35.6% of patients in Sino-RAD underwent medical treatment with in-hospital mortality of 42.5%, and 52.6% underwent surgery with mortality of 5.3%. For type-B AAD, 21.3% of patients underwent medical treatment with in-hospital mortality of 9.8%, 4.4% underwent surgery with mortality of 8.0%, and 69.6% underwent endovascular treatment with mortality of 2.5%.
According to data of 2017 from the HQMS in China, the median LOS in hospitals was 14 days and the average hospitalization cost was 152.5 thousand CNY for thoracic endovascular aortic repair. The estimates were 18 days and 138.6 thousand CNY for the Bentall procedure, and 19 days and 230.3 thousand CNY for synthetic interposition graft replacement of the aortic arch.
A screening program was performed among 5402 at-risk residents aged ≥40 years from 3 urban and 2 rural communities in Middle China. The prevalence of abdominal aortic aneurysm (AAA) was 0.33%. The growth rate of AAA in Chinese population ranged from 0.18 cm/year to 0.75 cm/year. The pooled mean growth rate for individuals with small AAA (diameters measuring 3.0–4.9 cm) was 0.28 cm/year and for individuals with large AAA (diameters ≥5.0 cm) was 0.75 cm/year.
In 2017, the median LOS in hospitals was 18 days and the average hospitalization cost was 112.3 thousand CNY for the treatment of AAA by synthetic interposition graft replacement of abdominal aorta in China. For endovascular aortic repair, the average hospitalization cost was 154.2 thousand CNY, and the median LOS decreased from 15 days in 2015 to 12 days in 2017.
Data from CHS indicated that 6.6% of the Chinese adult population aged ≥35 years (an estimated 45.3 million individuals) had PAD. Among those with PAD, 1.9% (an estimated 0.86 million individuals) received revascularization. PAD is highly associated with current smoking, DM, hypercholesterolemia, and hypertension. Current smoking was the strongest risk factor, with a meta-odds ratio of 2.62 (95% CI: 1.44–4.76).
The Screening and Intervention Project for Stroke High-risk Populations was conducted in the urban and rural communities of China from 2014 to 2015. A total of 106,918 subjects aged ≥40 years were examined by carotid ultrasound and included in the analysis. Approximately 0.5% of participants had carotid stenosis ≥50%.
A national multicenter registry study enrolled 9346 patients hospitalized with ischemic stroke from June 2015 to May 2016. The prevalence of atherosclerotic stenosis ≥50% was 0.9% for common carotid artery, 6.9% for internal carotid artery, and 1.1% for terminal of internal carotid artery, respectively.
Data from the Carotid Atherosclerosis Risk Assessment II (CARE-II) Study indicated that in Chinese patients with recent cerebral ischemic symptoms, the prevalence of a high-risk plaque (HRP, defined as plaques with luminal surface disruption, a lipid-rich necrotic core occupying >40% of the wall, or intraplaque hemorrhage) detected by carotid magnetic resonance imaging was 28%, nearly 1.5 times more prevalent than severe stenosis (≥50%). Approximately two-thirds of HRPs were found in arteries with <50% stenosis.
Renal artery stenosis (RAS) is a common peripheral manifestation of atherosclerosis in middle-aged and elderly. A single-center retrospective analysis of 2905 patients with RAS during an 18-year period in China found that the proportion of atherosclerotic RAS increased obviously over time from approximately 50% in the year 1999–2000 to nearly 85% in 2015–2016. The proportion of RAS caused by Takayasu arteritis decreased gradually over time from 31% to 10%, and that caused by fibromuscular dysplasia did not essentially unchanged, fluctuating between 2.9% and 6.5%.
The interarm BP difference has been recognized as an indicator of PAD in the subclavian arteries. A prospective study in older Chinese people was conducted among residents from a newly urbanized suburban town in Shanghai. A total of 3133 participants with a mean age of 69 years were included in the analysis. The prevalence of an interarm BP difference ≥15 mmHg was 1.75%. A total of 1793 consecutive inpatients diagnosed with subclavian artery stenosis between 1999 and 2017 were included in a single-center study. The prevalence of atherosclerosis was 95.9% in patients aged >40 years, and that of Takayasu arteritis was 90.5% in those aged ≤40 years.
Coronavirus disease 2019 (COVID-19)-related myocardial injury
A meta-analysis of 7679 patients from 53 studies showed that myocardial injury occurred in 21% of COVID-19 patients. An increased rate was observed in non-survivors (66%) and patients with severe COVID-19 (43%). The latter had a 4.74-fold increase in the risk of myocardial injury than patients with non-severe COVID-19.
Among patients who died of COVID-19, 40% were due to cardiovascular events. Underlying CVD increased the mortality rate of people with COVID-19.
More than 710,000 Chinese cancer patients were recruited in a population-based study. Overall, 18.0% of participants had at least one type of cardiovascular risk factor (CVRF) or CVD. The most common CVRF among the total cancer patients was hypertension (10.8%), followed by DM (5.3%) and dyslipidemia (1.2%). The highest prevalence of CVD was identified for stroke (2.7%), CHD (1.7%), and HF (0.6%). After adjustment for age, sex, tumor stage and treatment, multivariable regression analysis presented that HF was the most potent risk factor for all-cause mortality (HR, 1.79), followed by MI (HR, 1.50).
Rehabilitation after CVDs
A survey was conducted among 991 hospitals (870 tertiary hospitals, 107 secondary hospitals, and 14 community hospitals) in 2016. Cardiac rehabilitation was carried out in 23% of all hospitals (22% in tertiary hospitals and 30% in secondary hospitals). In-hospital phase-I and phase-II cardiac rehabilitation was carried out in 13.32% and 17.26%, respectively, of hospitals. It was estimated that only 13.2 hospitals per 100 million inhabitants could operate cardiac rehabilitation. Most of them were located in cities, whereas only a few were in suburbs and rural areas. All cardiac-rehabilitation programs reported caring for patients with PCI and HF, 92% for those with MI or pacemaker implantation, 69% for CABG or heart-valve surgery, and 62% for stable CCDs and stable angina.
Rehabilitation after stroke
From 2009 to 2018, the number of private rehabilitation hospitals and the capacity of inpatient beds had increased significantly in China. A national survey in 2009 found that there were 16,000 physicians, 14,000 therapists, and 12,000 nurses involved in medical rehabilitation. The data in 2018 reported 38,260 physicians and 15,514 nurses in rehabilitation hospitals.
Data from 1,552,248 in-patient medical-record front sheets were retrieved by the National Center for Healthcare Quality Management in Rehabilitation Medicine from 459 hospitals in China through HQMS. The discharge time was between January 1, 2013, and December 31, 2018. In tertiary hospitals with rehabilitation ward, the average LOS was 21.53 days and hospitalization cost was 810 CNY per day. The proportion of rehabilitation-related cost (including those on rehabilitation and physiotherapy) in the total expenditure increased annually from 11.39% (1959 CNY) in 2013 to 17.79% (3204 CNY) in 2018, but that of the cost on drugs (including those on Western medicine, Chinese patent medicine, and Chinese herbal medicine) decreased from 36.14% to 22.43%.
Data for 19,294 acute IS patients admitted to 219 hospitals from 2012 to 2013 were analyzed in the China National Stroke Registry II study. Among patients, 59.4% were assessed for rehabilitation. Rates of rehabilitation assessment varied among 219 hospitals (interquartile range (IQR), 41.4%–83.3%). Rehabilitation in hospital was provided by a rehabilitation therapist for 50.3% of patients, and 34.3% of patients were assessed by a nurse or physician.
Basic research and device development of CVDs
From 2019 to 2020, 58 articles with both the corresponding author and principal author(s) from mainland China had been published in the field of basic research [Figure 13]. Their subjects focused on the anatomy, development, and function of the heart and vasculature, as well as pathogenesis of CVD. According to research interests, 46 articles were on heart diseases, and 12 on vasculopathies (IHD, cardiomyopathy, myocarditis, HF, arrhythmia, atherosclerosis, and abnormal development). Hot topics included application of single-cell sequencing in cardiovascular development and diseases, development and regeneration of cardiomyocytes, the role of inflammatory cells in the development and progression of CVD, and gene therapy.
From January 1, 2019, to August 31, 2020, a total of 39 medical devices had been approved by the National Medical Products Administration for evaluation of innovation. Among them, 12 (30.8%) were cardiovascular products and 34 (87.2%) were invented by domestic manufacturers, which indicated that innovation in cardiology played a leading role in the field of medical devices in China.
From September 1, 2019, to October 22, 2020, 141 registration certificates of class-III medical devices in the field of cardiology had been approved by the National Medical Products Administration. Among them, 96 were domestic products, and 3 had been selected for national evaluation of innovative medical devices. Among the 96 domestic products, 69 were for interventional procedures, 5 for first-aid, 4 for diagnosis, 4 for imaging, 2 for open operation, 3 for artificial intelligence software, 1 for blood flow measurement system, 1 for cardiopulmonary bypass, and 1 for other uses.
With regard to the number of registration certificates approved in each province, the distribution of class-III medical devices in the field of cardiology still varied greatly among administrative regions. Guangdong enjoyed the largest proportion in China (28 registration certificates in 1 year), followed by Shanghai, Jiangsu, and Beijing. No certificate had been approved in more than other 20 provinces.
With the progress of modern science and technology, several novel medications in the field of cardiology have been developed in China. Their efficacy and safety have been confirmed in clinical studies/practice, which brings hope to the treatment of CVD. In addition, outside the framework of current guideline-oriented pharmacotherapy, traditional Chinese medicine has been explored for the treatment of CVD, and some of them have been proven to be applicable for evidence-based medicine.
Economic cost of CVDs
In 2018, the number of inpatient discharges from hospitals with CVD as the principal diagnosis was 23.1613 million in China, accounting for 12.80% of all discharges due to various diseases in the same period. Among the overall discharges, the number of discharges was 11.4239 million (6.31%) for inpatients with cardiac disease and 11.7374 million (6.48%) for those with cerebrovascular disease [Figure 14].
The proportion of discharges for inpatients with IHD (8.5588 million, including 0.9521 million acute MIs) or IS (7.7234 million) was the highest among that for patients with any type of CVD, and was 36.95% and 33.35%, respectively.
From 1980 to 2018, the number of hospital discharges for CVD in China increased by 9.73% annually, faster than that of all discharges due to various diseases (6.34%) in the same period. The top-three diseases in the annual growth rate of discharges were IS (12.03%), IHD (11.22%), and acute MI (10.94%). The estimate was 13.45% for DM [Figure 15].
In 2018, hospitalization costs were 111.982 billion CNY for IHD (including 27.496 billion CNY for acute MI), 72.674 billion CNY for stroke (including 28.190 billion CNY for ICH) [Figure 16], 16.667 billion CNY for hypertension, and 33.172 billion CNY for DM. The annual growth rate of hospitalization costs from 2004 in real terms was 26.89%, 18.65%, and 14.00%, respectively, for patients with acute MI, IS, and ICH.
In 2018, the average cost per hospitalization was 13,083.90 CNY for patients with IHD (28,879.30 CNY for acute MI), 9409.64 CNY for IS (18,863.63 CNY for ICH) [Figure 17], 6322.54 CNY for hypertension, and 7773.90 CNY for DM. The annual growth rate of average cost per hospitalization from 2004 in real terms was 6.09%, 1.26%, and 4.73%, respectively, for patients with acute MI, IS, and ICH.
Conflicts of interest
Editor note: Shengshou Hu is an Associate Editor of Cardiology Discovery. The article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research groups.