Details of the study design and data resource profile of the CCDRFS have been reported previously (16–18). To be brief, the CCDRFS-Guangzhou study is a representative cross-sectional survey assessing the prevalence of non-communicable diseases and related risk factors, which recruited permanent residents aged over 18 years from all 11 districts in Guangzhou. Participants were selected based on a multistage stratified sampling framework with probability proportional to size to ensure the representativeness of the study population (Supplementary Figure S1). First, we randomly selected 1/3 of the communities in districts with ≥15 communities and five communities in those with <15 communities. The number of communities selected was proportional to the number of primary medical and healthcare institutions within each district. In all 11 districts of Guangzhou, we included a total of 69 community/township healthcare centers and then randomly selected two residential committees/villages from each community/township. Further, a total of 5,000 households were randomly selected from the 138 committees/villages using cluster sampling, and all family members aged 18 years and older who have been living at their current residence for more than six months were enrolled. Finally, a total of 15,727 residents were enrolled. After excluding participants with missing information on demographics or key variables used for predicting 10-year ASCVD risk (n = 562), a total of 15,165 participants aged 18 years or older were included in the current analysis. When comparing the baseline characteristics between those included and excluded in the current analysis, we found that those excluded due to missing information were more likely to be men and younger (Supplementary Table S1). The study protocol was approved by the ethical committee of the Guangzhou Center for Disease Control and Prevention. All participants provided written informed consent.

Face-to-face interviews were conducted to collect information on demographic characteristics (sex, age, education level, occupation, marital status, and medical insurance status), health-related lifestyle behaviors (smoking, drinking, physical activity), and medical history by trained staffs during home visits using standardized protocols (16). Physical measurements (blood pressure, height, weight, waist and hip circumferences) and biochemical samples were centrally collected in community health centers. Fasting blood samples were drawn and transported to Guangzhou Center for Disease Control and Prevention within six hours of collection. Samples were analyzed for total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), blood glucose and homocysteine (HCY) were measured using enzyme colorimetry (Roche COBAS C501 automatic biochemical analyzer). Uric acid creatinine and urea nitrogen were measured using colorimetry (Roche c702 automatic biochemical analyzer).

Based on the status of smoking self-reported at the time of survey and referred to the definition of Global Adults Tobacco Survey (19), individuals were categorized into three groups: never, former, and current smokers. Respondents were asked whether they had ever drunk any kind of alcoholic beverage over the past 12 months; if yes, they were asked to provide information on frequency, types and quantity consumed in a typical day. Overdrinking was defined as consuming alcohol at least three times a week for more than six months. Sleep debt was defined as a sleeping duration of less than 7 h within 24 h. Physical activity was collected using the short-form International Physical Activity Questionnaire (20), and individuals did moderate or vigorous physical activity <150 min per week were considered as physical inactivity. Hypertension was defined as a baseline systolic and diastolic blood pressure of at least 140/90 mmHg, self-reported history of hypertension. Diabetes was defined as fasting glucose greater than or equal to 7 mmol/L or self-reported history of diabetes. Hyperlipidemia was defined as TC than or equal to 6.2 mmol/L, LDL-C than or equal to 4.1 mmol/L, TG than or equal to 2.3 mmol/L, HDL-C than or equal to 1.0 mmol/L, or self-reported history of hyperlipidemias. Information on medication use included a prescription of antiplatelet therapy, blood pressure control, lipid-lowering, or glucose control during the previous two weeks. Awareness and treatment of common risk factors (hypertension, diabetes, and hyperlipidemia) were assessed in participants with corresponding risk factors. Besides, we evaluated whether participants had their risk factors controlled as BP < 130/80 mm Hg; LDL-C < 2.6 mmol/L; not a current smoker; BMI of 18.5–24.0 kg/m²; and achieving physical activity targets (≥150 min of moderate-intensity physical activity per week or ≥75 min of high-intensity physical activity per week) (21).

Ten-year ASCVD (including nonfatal myocardial infarction, fatal or nonfatal stroke, and CVD death) risk was evaluated using the risk assessment model recommended in the Chinese Guideline for the Prevention of Cardiovascular Disease (14). The risk prediction chart was developed from a large multi-provincial cohort, which has been suggested to show good discrimination and calibration when predicting 10-year cardiovascular events, coronary heart diseases, and lifetime CVD risk (22–24). The Chinese guideline suggests evaluating the ASCVD risk hierarchically and categorizing individuals into different risk stratifications as low, moderate, high, and extremely high levels. Individuals with a prior history of CVD were categorized as extremely high risk. Individuals who met at least one of the following criteria were directly categized as high risk: (1) diabetic patients aged 40 years or older; (2) LDL-C ≥ 4.9 mmol/L (190 mg/dl) or TC ≥ 7.2 mmol/L (280 mg/dl); (3) SBP ≥ 180 mmHg or DBP ≥ 110 mmHg; (4) smoking ≥30 cigarettes per day. For the remaining people, the predicted 10-year risk for ASCVD was calculated based on age, sex, smoking status, blood pressure, and lipids levels (TC, LDL-C, HDL-C) by using the risk prediction charts. Detailed information for the risk assessment flowchart is listed in Supplementary Figure S2. Individuals with a predicted 10-year risk for ASCVD of <5%, 5%–9%, and ≥10% are categorized as low, moderate, and high risk, respectively. Similar to the guidelines from the American Heart Association and American College of Cardiology (25), the Chinese guideline recommends that primary prevention of ASCVD should be based on risk assessment tools. In this study, we categorized participants into low-to-moderate risk, high risk, and extremely high risk (those with established CVD). CVD was defined as a history of stroke, myocardial infarction, angina pectoris, coronary artery bypass grafting, or percutaneous coronary intervention.

In this study, we reported the estimates of the prevalence of high ASCVD risk; rates of awareness, treatment, and control of related risk factors. Sampling weights were used in the analyses to improve the representativeness. The weights included sampling weights, non-response weights, and population weights (using the 7th population census of Guangzhou in 2020). The weighted adjusted percentages and 95% confidence intervals (95% CI) were used. The comparison of the ratios of different population characteristics was performed using the corrected Rao-Scott χ² test based on a complex sampling design. Besides, we also assessed the association between participant characteristics and predicted high 10-year ASCVD among those without established CVD using logistic regression based on a complex sampling design. We further explored if the associations varied by sex and tested the interaction using multiplicative models by including the product terms. To compare the rates of awareness, treatment, and control between key demographic subgroups, we also applied logistic regression models with a complex sampling design adjusting for age, sex, urban or rural residency, and education levels. Statistical analysis was performed using SPSS V.21.0. Two-sided P-value <0.05 was considered statistically significant.

Among 15,165 participants included in the current analysis, 289 had established CVD, 3,075 had high 10-year ASCVD risk, and 11,801 had low-to-moderate 10-year risk. The weighted proportion of men was 51.9%, and the mean age was 41.27 ± 0.52 years (Table 1). Compared to those with low-to-moderate risk, participants with CVD and predicted 10-year ASCVD risk ≥10% were more likely to be men, with older age, and less educated, and they were also more prevalent to have metabolic risk factors (including obesity, hypertension, abnormal HCY, and renal function damage). Whereas, participants with high 10-year risk were more frequently to smoke and drink alcohol currently, have sleep debt, expose to second-hand smoke, and have diabetes and dyslipidemia than those with low-to-moderate risk or with established CVD.

The overall standardized prevalence of high 10-year ASCVD risk was 13.8% (95% CI, 12.4%–15.3%), and 0.9% (95% CI, 0.7%–1.2%) had prevalent CVD (Table 2). The prevalence of high predicted 10-year ASCVD risk was higher in men (weighted prevalence, 17.8; 95% CI, 15.1%–21.0%) compared to women (9.4%; 95% CI, 8.1%–10.8%), and significantly increased by age, with 35.6% (95% CI, 32.9%–38.4%) of people aged 65 years or older predicted to be with high risk. Moreover, the prevalence of high 10-year ASCVD risk was similar between urban and rural areas (urban: 13.1%; 95% CI, 11.2%–15.2% vs. rural: 15.3%; 95% CI, 13.3%–17.6%), but the prevalence was significantly higher in those with primary education (27.1; 95% CI, 23.9%–30.5%) than those with high education levels (5.6%; 95% CI, 4.5%–7.1%). The variations in the prevalence of CVD by key demographic characteristics showed similar patterns to those in high ASCVD risk. Among those who were estimated to have a moderate risk of 10-year ASCVD and aged <55 years, 46.3% (95% CI, 39.9%–52.9%) were assessed to have a high lifetime cardiovascular risk (Supplementary Table S2). The prevalence of high lifetime ASCVD risk was higher among men, those younger than 35 years, and those with high levels of education.

Table 3 shows the association between individual risk factors and high ASCVD risk among participants without established CVD. Older age, rural areas, higher BMI, abdominal obesity, overdrinking, sleep debt second-hand smoke exposure, and abnormal HCY were significantly associated with a predicted 10-year risk higher than 10%. When stratified by sex, location of residence, education level, overdrinking and second-hand smoke exposure had a stronger association with predicted ASCVD risk in men. By contrast, age and renal function damage had more pronounced associations among women.

The awareness rates of common cardiovascular risk factors were highest among those with established CVD, followed by those with high 10-year ASCVD risk, and lowest among those with low or moderate risk. Among participants with high 10-year risk, the awareness rates for hypertension, diabetes, and hyperlipidemia were 48.0% (95% CI, 42.8%–53.4%), 48.3% (95% CI, 43.0%–53.7%), and 17.9% (95% CI, 14.4%–22.1%), respectively (Table 4). The awareness rates of these three risk factors were higher in women compared with men among those without known CVD, whereas the awareness rates of hypertension and hyperlipidemia were higher in men than women among participants with established CVD. When stratified by location of residence, urban residents consistently had a higher proportion of risk factor awareness than those living in rural areas. After adjusting for those key demographic variables, the awareness rate of diabetes was significantly higher in women than men among those with low or moderate risk [odds ratio (OR), 5.75; 95% CI, 1.78–18.57]. Among those with high ASCVD risk, hypertension awareness was higher in women (OR, 1.67; 95% CI, 1.16–2.41) and diabetes awareness was higher in urban residents (OR, 2.12; 95% CI, 1.47–3.05). In terms of established CVD, the awareness rates of hypertension (OR, 4.36; 95% CI, 1.04–18.32) and hyperlipidemia (OR, 6.31; 95% CI, 1.43–27.76) were both significantly higher in urban residents.

The proportions of drug use in prevention were relatively low in primary prevention, with the rates of using BP-lowering, glucose-lowering, lipid-lowering, and aspirin being 37.7% (95% CI, 32.8%–42.8%), 41.4% (95% CI, 35.8%–47.3%), 6.7% (95% CI, 4.5%–10.0%), and 1.0% (95% CI, 0.6%–1.8%), respectively (Figure 1A and Supplementary Table S3). By contrast, the proportion of medication use was relatively higher in those with established CVD, which might be related to reverse causality. When stratified by sex, we found that women were more likely to receive BP lowering drugs (OR, 1.58; 95% CI, 1.05–2.38) in primary prevention and glucose-lowering medications in secondary prevention (OR, 5.62; 95% CI, 1.19–26.57). Moreover, the proportions of BP-lowering drugs, lipid-lowering drugs, glucose-lowering drugs, and aspirin were significantly higher in urban residents than those living in rural areas in primary prevention; and urban residents were also more likely to use aspirin in secondary prevention.

As for risk factor control, only 29.3% (95% CI, 25.7%–33.2%), 16.8% (95% CI, 15.0%–18.6%), and 36.0% (95% CI, 31.1%–41.2%) of individuals with high ASCVD risk could have their blood pressure, LDL-C, and body weight well controlled (Figure 1B). Women had higher proportions of blood achieving ideal blood pressure levels and weight status in primary prevention compared to men, whereas the prevalence of LDL-C < 2.6 mmol/L in secondary prevention was twice higher in men than that in women (58.7% vs. 25.9%). When stratified by location of residence, rural participants had significantly lower rates of BP control and non-smokers in primary prevention, as well as lipid control and achieving physical targets in secondary prevention.