Assessment of Prevalence, Awareness, and Characteristics of Isolated Systolic Hypertension Among Younger and Middle-Aged Adults in China

Key Points

Question  What are the characteristics of young and middle-aged adults with isolated systolic hypertension in China, and what is the prevalence and awareness of isolated systolic hypertension among this population?

Findings  In this cross-sectional study of young and middle-aged adults in China, isolated systolic hypertension was identified in 27% of participants with hypertension, 87% of whom had not received treatment; less than 7% of individuals with untreated isolated systolic hypertension were aware of having hypertension. Among individuals with isolated systolic hypertension, 16% had systolic blood pressure of 160 mm Hg or higher, but awareness rates remained low even in this group.

Meaning  In this study, a substantial proportion of young and middle-aged adults with hypertension had isolated systolic hypertension; there is an opportunity to improve awareness of isolated systolic hypertension among this population.

Importance  Isolated systolic hypertension (ISH) is increasing in prevalence among young and middle-aged adults. However, most studies of ISH are limited to older individuals, and a substantial knowledge gap exists regarding younger adults with ISH.

Objective  To assess the prevalence, awareness, and characteristics of ISH among younger and middle-aged adults in China.

Design, Setting, and Participants  This cross-sectional study was performed as part of the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project, which enrolled 3.1 million community residents aged 35 to 75 years from all of the 31 provinces in China between December 15, 2014, and May 15, 2019. The present analysis included only participants younger than 50 years. Data were analyzed from May to November 2019.

Main Outcomes and Measures  Prevalence and awareness of ISH (defined as systolic blood pressure of 140 mm Hg or higher and diastolic blood pressure of less than 90 mm Hg) and individual characteristics of participants with ISH.

Results  Among 898 929 participants aged 35 to 49 years, the mean (SD) age was 43.8 (3.9) years; 548 657 participants (61.0%) were women, and 235 138 participants (26.2%) had hypertension. Of those with hypertension, 62 819 participants (26.7%; 95% CI, 26.5%-26.9%) had ISH (mean [SD] age, 45.0 [3.5] years; 41 417 women [65.9%]), and 54 463 of those with ISH (86.7%; 95% CI, 86.4%-87.0%) had not received treatment. The prevalence of ISH was higher among individuals who were older, were female, were farmers, resided in the eastern region of China, and had an educational level of primary school or lower. Women and older individuals were more likely to have ISH than to be normotensive or to have other hypertension subtypes. Participants who were obese, currently used alcohol, had diabetes, and experienced previous cardiovascular events were more likely to have other types of hypertension and less likely to have normotension than to have ISH. Among the 54 463 participants with ISH who had not received treatment, only 3682 individuals (6.8%; 95% CI, 6.6%-7.0%) were aware of having hypertension, and awareness rates remained low even among those with systolic blood pressure of 160 mm Hg or higher (7135 individuals [13.1%; 95% CI, 12.4%-13.9%]).

Conclusions and Relevance  In this study, ISH was identified in 1 of 4 young and middle-aged adults with hypertension in China, most of whom remained unaware of having hypertension. These results highlight the increasing need for better guidance regarding the management of ISH in this population.

Isolated systolic hypertension (ISH), a subtype of hypertension, is experienced by more than 40% of adults with untreated hypertension.^1-3 Among those who do receive treatment, control of systolic blood pressure (SBP) is particularly challenging compared with control of diastolic blood pressure (DBP), making ISH the most common subtype of hypertension among patients with uncontrolled hypertension.^4-7 Isolated systolic hypertension is a well-studied condition that has received attention across various hypertension guidelines. However, ISH is disproportionately found in older adults, and many of the disease management recommendations are based on studies and data of older individuals.^1,8-13

Young and middle-aged adults are experiencing an increasing prevalence of ISH,^14-16 which can increase their risk of heart disease and stroke.¹⁷ Younger individuals with ISH may have distinct characteristics that require exploration given that the pathophysiologic characteristics of ISH may differ from those of older individuals (eg, aortic stiffness in older adults and increased cardiac output or stroke volume in younger adults), which can have implications for disease management.¹⁸ However, most previous studies of ISH have focused on older individuals (>50 years),^1,19 and the few studies of younger individuals with ISH in China have only provided information regarding the overall prevalence of ISH in this population.¹⁶ Thus we lack a comprehensive understanding of the prevalence, awareness, and characteristics of young and middle-aged individuals with ISH in the Chinese population and how these factors may vary across diverse subgroups of the population.

The China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project (China PEACE MPP), a large-scale population-based screening project, provided a suitable platform to examine ISH among young and middle-aged adults given the project’s large data set (N = 3 094 655) and recruitment of participants at the community level. We performed a cross-sectional study of young and middle-aged participants from the China-PEACE MPP to describe the prevalence, awareness, and individual characteristics of ISH among this population.

Details of the design of the China PEACE MPP have been described previously.²⁰ In brief, between December 15, 2014, and May 15, 2019, 244 sites (146 rural counties and 98 urban districts) were selected by a convenience sampling strategy from county-level geographic regions in 31 provinces of mainland China. Participants were enrolled in the China PEACE MPP if they were aged 35 to 75 years and had a Hukou (an official record that identifies area residents) for a region selected for the study. Participants were recruited through publicity campaigns in the media and by mail. The study was approved by the central ethics committee of the China National Center for Cardiovascular Disease and the institutional review board of Yale University. All enrolled participants provided written informed consent. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.²¹

Of the 3 094 655 participants enrolled in the China PEACE MPP during the study period, 899 128 young and middle-aged adults (29.1%) between ages 35 and 49 years were selected for the present cross-sectional study. We excluded 129 participants who were missing data for age and 70 participants who were missing data for blood pressure (BP) or who had BP levels that were extremely high or low (ie, SBP levels <70 mm Hg or >270 mm Hg and DBP levels <30 mm Hg or >150 mm Hg) (eFigure in the Supplement). After exclusions, the final sample comprised 898 929 young and middle-aged adults. Participants with missing data on covariates (including geographic region of residence, educational level, employment status, occupation, marital status, household income, current smoking status, and current alcohol use) were analyzed as a separate subgroup that was categorized as unknown.

Blood pressure was measured twice (after 5 minutes of quiet rest in a seated position at an interval of 1 minute) on each participant’s upper right arm using an electronic BP monitor (Omron HEM-7430; Omron Corp); measurement was performed by trained staff according to a standard operating procedure (eMethods in the Supplement). Participants were advised to stop smoking 15 minutes before the BP measurement and to turn off their mobile phones during the BP measurement. Both of the BP values and their means were recorded. If the difference between the two SBP measurements was greater than 10 mm Hg, a third BP measurement was performed; in such cases, the mean SBP and DBP were calculated using the last 2 measurements. The mean SBP and DBP values were used for all analyses.

Information on the receipt of antihypertensive, hypoglycemic, hypolipidemic, and antiplatelet medications within the past 2 weeks was collected during an in-person interview. Data regarding the participants’ sociodemographic characteristics, health behaviors, medical histories, and cardiovascular risk factors were also recorded during these in-person interviews. Height and weight were measured according to standard protocols, and body mass index was calculated as weight in kilograms divided by height in meters squared.

Because this study was performed in a Chinese cohort, we used the Chinese Guidelines for the Management of Hypertension²² to define hypertension and classify different hypertension subtypes. Hypertension was defined as a self-reported previous diagnosis of hypertension or receipt of antihypertensive medication in the past 2 weeks or as a mean SBP level of 140 mm Hg or higher or a mean DBP level of 90 mm Hg or higher at the screening visit. Isolated systolic hypertension was defined as a mean SBP level of 140 mm Hg or higher and a mean DBP level of less than 90 mm Hg. Isolated diastolic hypertension (IDH) was defined as a mean SBP level of less than 140 mm Hg and a mean DBP level of 90 mm Hg or higher, and systolic-diastolic hypertension (SDH) was defined as a mean SBP level of 140 mm Hg or higher and a mean DBP level of 90 mm Hg or higher, regardless of the participant’s treatment status. Controlled hypertension was defined as a self-reported previous diagnosis of hypertension or receipt of antihypertensive medication and an SBP level of less than 140 mm Hg and a DBP level of less than 90 mm Hg. Participants who did not have a history of receiving antihypertensive medication and who had an SBP level of less than 140 mm Hg and a DBP level of less than 90 mm Hg were defined as having normotension.

Participants were considered to be aware of having hypertension if they responded yes to the question, “Have you ever been diagnosed with hypertension?” Participants were considered to have received treatment for hypertension if they reported receiving an antihypertensive medication (including western or traditional Chinese medications) currently or within the last 2 weeks. Obesity was defined as a body mass index of 28 kg/m² or higher, which was in accordance with the recommendations of the Working Group on Obesity in China.²³

We estimated the prevalence of ISH among the overall study participants and among those with hypertension, and we compared their characteristics with individuals who had other hypertension subtypes. We also described the distribution of SBP levels among men and women with ISH across different age groups. Next, we assessed the awareness of having hypertension by sex and SBP level among individuals with ISH who had not received treatment. We then developed multivariable generalized linear mixed models with a logit link function and township-specific random intercepts (to control for geographic autocorrelation) to identify individual characteristics that were independently associated with ISH prevalence and awareness. We compared participants with ISH with those with normotension, IDH, and SDH using separate models. Explanatory variables included participants’ age, sex, marital status, annual household income, educational level, health insurance status, geographic region of residence, current smoking status, current alcohol use, obesity, physician-diagnosed diabetes, and previous cardiovascular events (myocardial infarction or stroke).

All analyses were conducted using R software, version 3.33 (R Foundation for Statistical Computing), and SAS software, version 9.4 (SAS Institute), with P < .05 considered statistically significant. Data were analyzed from May to November 2019.

Among 898 929 young and middle-aged adults included in the final sample, the mean (SD) age was 43.8 (3.9) years; 548 657 participants (61.0%) were women, and 235 138 participants (26.2%) had hypertension (Table 1). A total of 62 819 participants (26.7% of those with hypertension, or 7.0% of the total sample) had ISH, and 172 319 participants (73.3% of those with hypertension, or 19.2% of the total sample) had other types of hypertension (Table 2). Among those with other types of hypertension, 35 448 individuals (20.6%, or 3.9% of the total sample) had IDH, 116 682 individuals (67.7%, or 13.0% of the total sample) had SDH, and 20 189 individuals (11.7%, or 2.2% of the total sample) had controlled hypertension. Based on age and sex standardization of our results compared with data from all of the 31 provinces included in the 2010 Chinese census, the prevalence of overall hypertension and ISH among young and middle-aged adults was 24.0% and 7.0%, respectively.

Among 235 138 young and middle-aged participants with hypertension, 62 819 individuals (26.7%) had ISH (mean [SD] age, 45.0 [3.5] years; 41 417 women [65.9%]). A total of 54 463 individuals (86.7%) with ISH had not received treatment. Overall, the prevalence of ISH was higher among older age groups (39 659 of 140 420 individuals [28.2%; 95% CI, 28.0%-28.5%] aged 45-49 years vs 5455 of 24 811 individuals [22.0%; 95% CI, 21.5%-22.5%] aged 35-39 years), women (41 417 of 124 893 women [33.2%; 95% CI, 32.9%-33.4%] vs 21 402 of 110 245 men [19.4%; 95% CI, 19.2%-19.7%]), participants residing in the eastern region of China (26 249 of 89 137 individuals [29.4%; 95% CI, 29.2%-29.8%] in the eastern region vs 20 022 of 81 962 individuals [24.4%; 95% CI, 24.1%-24.7%] in the western region), participants with lower educational levels (21 978 of 72 373 individuals [30.4%; 95% CI, 30.0%-30.7%] with a primary school education or lower vs 5907 of 30 458 individuals [19.4%; 95% CI, 19.0%-19.8%] with a college education or higher), participants who were employed (55 624 of 208 813 employed individuals [26.6%; 95% CI, 26.5%-26.8%] vs 1072 of 5001 unemployed individuals [21.4%; 95% CI, 20.3%-22.6%]), and participants who were farmers (31 355 of 107 347 farmers [29.2%; 95% CI, 28.9%-29.5%] vs 30 416 of 123 282 nonfarmers [24.7%; 95% CI, 24.4%-24.9%]) (Table 2). In addition, approximately 1 in 5 participants with obesity (13 213 of 64 894 individuals [20.4%; 95% CI, 20.1%-20.7%]), diabetes (8498 of 37 228 individuals [22.8%; 95% CI, 22.4%-23.3%]), current smoking (10 742 of 57 406 individuals [18.7%; 95% CI, 18.4%-19.0%]), current alcohol use (10 355 of 57 591 individuals [18.0%; 95% CI, 17.7%-18.3%]), previous myocardial infarction (234 of 1341 individuals [17.4%; 95% CI, 15.4%-19.5%]), and previous stroke (607 of 3570 individuals [17.0%; 95% CI, 15.8%-18.2%]) had ISH.

Overall, approximately 9737 of 62 819 individuals (15.5%; 95% CI, 15.3%-15.8%) with ISH (both treated and untreated) had an SBP level of 160 mm Hg or higher. The proportion of participants with ISH who had an SBP level of 160 mm Hg or higher was greater among women than among men across all ages (for ages 35-39 years, 630 of 2923 women [21.6%; 95% CI, 20.1%-23.1%] vs 395 of 2532 men [15.7%; 95% CI, 14.2%-17.1%]; for ages 40-44 years, 1716 of 10 855 women [16.3%; 95% CI, 15.5%-16.9%] vs 953 of 6850 men [13.9%; 95% CI, 13.1%-14.8%]; for ages 45-49 years, 4417 of 27 639 women [16.0%; 95% CI, 15.6%-16.4%] vs 1606 of 12 020 men [13.3%; 95% CI, 12.8%-14.0%]) (Figure 1).

Compared with individuals with normotension (n = 663 791), participants with ISH were more likely to be obese (70 161 individuals [10.6%; 95% CI, 10.5%-10.6%] vs 13 213 individuals [21.0%; 95% CI, 20.7%-21.4%], respectively), currently use alcohol (97 917 [14.8%; 95% CI, 14.7%-14.8%] vs 10 355 individuals [16.5%; 95% CI, 16.2%-16.8%]), have diabetes (47 632 individuals [7.2%; 95% CI, 7.1%-7.2%] vs 8498 individuals [13.5%; 95% CI, 13.3%-13.8%]), and have a previous history of stroke (1993 individuals [0.3%; 95% CI, 0.3%-0.3%] vs 607 individuals [1.0%; 95% CI, 0.9%-1.0%]) (Table 1). Compared with participants who had other hypertension subtypes, such as IDH (n = 35 448) and SDH (n = 116 682), participants with ISH were more likely to be aged 45 to 49 years (39 659 individuals [63.1%; 95% CI, 62.8%-63.5%] with ISH vs 17 948 individuals [50.6%; 95% CI, 50.1%-51.2%] with IDH and 69 578 individuals [59.6%; 95% CI, 59.3%-59.9%] with SDH), female (41 417 individuals [65.9%; 95% CI, 65.6%-66.3%] with ISH vs 14 093 individuals [39.8%; 95% CI, 39.2%-40.3%] with IDH and 58 124 individuals [49.8%; 95% CI, 49.5%-50.1%] with SDH), have an educational level of primary school or lower (21 978 individuals [35.0%; 95% CI, 34.6%-35.4%] with ISH vs 9686 individuals [27.3%; 95% CI, 26.9%-27.8%] with IDH and 35 024 individuals [30.0%; 95% CI, 29.8%-30.3%] with SDH), be farmers (31 355 individuals [49.9%; 95% CI, 49.5%-50.3%] with ISH vs 15 377 individuals [43.4%; 95% CI, 42.9%-43.9%] with IDH and 52 730 individuals [45.2%; 95% CI, 44.9%-45.5%] with SDH), and reside in eastern regions of China (26 249 individuals [41.8%; 95% CI, 41.4%-42.2%] with ISH vs 11 774 individuals [33.2%; 95% CI, 32.7%-33.7%] with IDH and 42 887 individuals [36.8%; 95% CI, 36.5%-37.0%] with SDH) (Table 1).

In our multivariable analysis, when compared with participants with normotension, participants who were female, were older, were obese, currently used alcohol, had lower annual household income and lower educational levels, did not have health insurance, had a history of diabetes or cardiovascular events, and resided in eastern or central regions had a greater likelihood of ISH; however, marital status was not a substantial factor (Table 3). When compared with participants with IDH and SDH, participants with ISH were more likely to be older, be female, and reside in central or eastern regions but were less likely to have higher household income, educational levels of college or higher, previous cardiovascular events, and obesity and to currently smoke and use alcohol.

Among the 54 463 participants with ISH who had not received treatment (86.7% of the total participants with ISH), only 3682 individuals (6.8%) were aware of having hypertension, whereas 1736 of the 30 365 participants (5.7%) with IDH who had not received treatment and 15 526 of the 87 586 participants (17.7%) with SDH who had not received treatment were aware of having hypertension (eTable in the Supplement). Among participants with ISH who had not received treatment, awareness rates were higher among older age groups (2458 individuals [7.3%; 95% CI, 7.1%-7.6%] aged 45-49 years and 967 individuals [6.1%; 95% CI, 5.7%-6.4%] aged 40-44 years vs 257 individuals [5.1%; 95% CI, 4.5%-5.8%] aged 35-39 years), women (2474 women [7.0%; 95% CI, 6.7%-7.2%] vs 1208 men [6.4%; 95% CI, 6.0%-6.7%]), and individuals who lived in rural areas (2453 individuals [7.0%; 95% CI, 6.8%-7.3%] in rural areas vs 1221 individuals [6.3%; 95% CI, 5.9%-6.6%] in urban areas) and central or western regions (1089 individuals [7.7%; 95% CI, 7.3%-8.2%] in central regions and 1287 individuals [7.3%; 95% CI, 6.9%-7.7%] in western regions vs 1306 individuals [5.8%; 95% CI, 5.5%-6.1%] in eastern regions). Approximately 10% or less of participants with ISH who had 1 or more cardiovascular risk factor, including current smoking (706 individuals [7.5%; 95% CI, 7.0%-8.1%]), current alcohol use (715 individuals [7.9%; 95% CI, 7.3%-8.5%]), obesity (958 individuals [9.1%; 95% CI, 8.6%-9.7%]), and diabetes (679 individuals [10.3%; 95% CI, 9.6%-11.1%]), were aware of having hypertension. In addition, approximately 25% or less of participants with ISH who had a previous history of myocardial infarction (32 individuals [22.5%; 95% CI, 16.0%-30.3%]) or stroke (88 individuals [25.4%; 95% CI, 20.9%-30.3%]) were aware of having hypertension (eTable in the Supplement). Although awareness rates increased with age, they remained low among both sexes even after stratification by SBP level (Figure 2). For example, among individuals with an SBP level of 160 mm Hg or higher, awareness rates were 7.8% for men and 7.4% for women aged 35 to 39 years, and awareness rates were 13.3% for men and 15.4% for women aged 45 to 49 years.

In our multivariable analysis, older age, female sex, and the presence of cardiovascular risk factors (such as current smoking and alcohol use, obesity, history of diabetes, and previous cardiovascular events) remained significant factors associated with the awareness of having hypertension (Table 3). However, marital status, educational level, health insurance status, and geographic region were not substantial factors.

In this large population-based cross-sectional study, we found that ISH was present in approximately 1 of 4 young and middle-aged adults (26.7%) with hypertension in China, most of whom (86.7%) had not received treatment; only 6.8% of those who had not received treatment were aware of having hypertension. In addition, approximately 1 in 6 individuals (15.5%) with untreated ISH had an SBP level of 160 mm Hg or higher; however, awareness rates remained low (≤15.4%) in this group. Moreover, even among individuals with 1 or more cardiovascular risk factors and a history of cardiovascular events, approximately 90% and 75% of individuals with ISH, respectively, remained unaware of having hypertension.

Our study expands the existing literature on ISH in several ways. First, to our knowledge, our study is one of the largest to describe the current prevalence and characteristics of young and middle-aged adults with ISH in China, which allowed us to explore associations across a variety of diverse subgroups. We found that ISH was present in 26.7% of young and middle-aged adults with hypertension in China, which is consistent with the previously reported prevalence among cohorts from non-Chinese populations.^2,3,9,24 Young and middle-aged adults with ISH in China were more likely to be older, female, and obese and to currently use alcohol, have diabetes, and have a history of previous cardiovascular events compared with those with normotension, which is consistent with the associations previously reported in the literature for non-Chinese populations, particularly from studies in the US and Europe.^3,8,9,24,25 In addition, we found that young and middle-aged adults with ISH were more likely to have lower socioeconomic status and reside in the central or eastern regions of China than individuals with normotension, which, to our knowledge, has not been previously reported. These factors may be associated with the participants’ health care access, motivation to make healthy lifestyle choices, adherence to preventive health guidelines, and management of comorbidities associated with hypertension.²⁶

Second, our study is the first, to our knowledge, to describe the awareness of having hypertension among young and middle-aged adults with ISH in a contemporary Chinese population. We found that only 6.8% of untreated individuals with ISH were aware of having hypertension, and awareness rates remained low even among those with high SBP levels (≤15.4% among adults with SBP≥160 mm Hg) or a history of previous cardiovascular events (≤25.4%). These awareness rates are substantially lower than those for the overall population of individuals with hypertension in China (44.7%).²⁷ Younger adults are more difficult to reach through traditional clinic-based preventive programs because they may be less aware of the long-term benefits of early control of cardiovascular risk factors and therefore less likely to be in contact with the health system and less motivated to make lifestyle changes.^28-30 In addition, given that the clinical importance of the treatment of ISH in younger adults has been questioned in the past^31,32 and that most previous studies of ISH have focused on older individuals, there are currently no recommendations for the management of ISH in younger adults.^22,24,33 Thus our findings may be a reflection of the lack of clinical data in this population, and they highlight the need for clinical trials among this population.

This study has several limitations. First, patients who received treatment for ISH and decreased their SBP level to less than 140 mm Hg were classified as having controlled hypertension, which could have underestimated the burden of ISH in China. However, very few individuals who originally had ISH would have been classified as having controlled hypertension given the low hypertension treatment rates, and the even lower control rates, in China. Second, some individuals with hypertension could have experienced a preferential improvement in their DBP levels and may have been included in the ISH group, leading to overestimation of the rates for ISH. However, overestimation is unlikely to have been a substantial factor, as most individuals (86.7%) in the ISH group had not received treatment. Third, our current study design did not permit us to examine ISH in adults younger than 35 years. Fourth, because the China PEACE MPP is a large-scale population-based screening project, BP was only measured at a single visit. Considering the effect of regression to the mean, we may have overestimated the prevalence of hypertension and ISH. However, the effect of regression to the mean should not be substantial. Fifth, we used a convenience sample rather than a nationally representative sample for large-scale recruitment, which may have limited the generalizability of our findings to China despite their consistency with the age- and sex-standardized prevalence of ISH in the 2010 Chinese census data. Additionally, inclusion of this sample could have resulted in overestimation of the awareness and treatment rates because these participants would have been more likely to have contact with the health system.

In this large population-based cross-sectional study, we found that ISH was present in approximately 30% of young and middle-aged adults with hypertension in China, most of whom remained unaware of having hypertension. These results highlight the increasing need for improved awareness of ISH in this population and the need for better evidence-based guidance for the management of ISH among younger individuals.

Accepted for Publication: April 27, 2020.

Published: December 8, 2020. doi:10.1001/jamanetworkopen.2020.9743

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Mahajan S et al. JAMA Network Open.

Corresponding Author: Jing Li, MD, PhD, National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, 167 Beilishi Rd, Beijing 100037, People’s Republic of China (jing.li@fwoxford.org).

Author Contributions: Dr Hu and Ms Gao had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Mahajan and Feng were joint first authors, and Drs Krumholz and Li were joint senior authors.

Concept and design: Mahajan, Feng, Gupta, Liu, Zheng, Krumholz, Li.

Acquisition, analysis, or interpretation of data: Mahajan, Feng, Hu, Y. Lu, Murugiah, Gao, J. Lu, Spatz, Zhang, Krumholz, Li.

Drafting of the manuscript: Mahajan, Feng, Li.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hu, Gao.

Obtained funding: Li.

Administrative, technical, or material support: Mahajan, Feng, Zhang, Li.

Supervision: Y. Lu, Gupta, Krumholz, Li.

Conflict of Interest Disclosures: Dr Y. Lu reported receiving funding from the National Heart, Lung, and Blood Institute and the Yale Center for Implementation Science and being the recipient of a research agreement, through Yale University, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion outside the submitted work. Dr Gupta reported receiving grants from the National Heart, Lung, and Blood Institute; receiving personal fees from Arnold & Porter Kaye Scholer and the Law Offices of Ben C. Martin; and serving as a board member of Heartbeat Health outside the submitted work. Dr Spatz reported receiving funding from the Centers for Medicare and Medicaid Services to support quality measurement programs, the US Food and Drug Administration to support projects within the Yale–Mayo Clinic Center of Excellence in Regulatory Science and Innovation, the National Institute on Minority Health and Health Disparities to study precision-based approaches to diagnosing and preventing hypertension, and the National Institute of Biomedical Imaging and Bioengineering to study a cuffless blood pressure device outside the submitted work. In the past 3 years, Dr Krumholz received expenses and/or personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, the Siegfried and Jensen Law Firm, Arnold and Porter Law Firm, Martin/Baughman Law Firm, F-Prime, and the National Center for Cardiovascular Diseases in Beijing. He is an owner of Refactor Health and HugoHealth, and had grants and/or contracts from the Centers for Medicare & Medicaid Services, Medtronic, the US Food and Drug Administration, Johnson & Johnson, and the Shenzhen Center for Health Information. Dr Li reported receiving research grants, through Fuwai Hospital, from the People’s Republic of China for work to improve the management of hypertension and blood lipids and to improve care quality and patient outcomes of cardiovascular disease; receiving research agreements, through the National Center for Cardiovascular Diseases and Fuwai Hospital, from Amgen for a multicenter clinical trial assessing the efficacy and safety of omecamtiv mecarbil and for dyslipidemic patient registration; receiving a research agreement, through Fuwai Hospital, from Sanofi for a multicenter clinical trial on the effects of sotagliflozin; receiving a research agreement, through Fuwai Hospital, with the University of Oxford for a multicenter clinical trial of empagliflozin; and receiving a research agreement, through the National Center for Cardiovascular Diseases, from AstraZeneca for clinical research methods training outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by grant 2018YFC1312400 from the National Key Research and Development Program of the Ministry of Science and Technology of China (Dr Li), grant 2016-I2M-1-006 from the CAMS Innovation Fund for Medical Science (Dr Zheng), grant B16005 from the 111 Project of the Ministry of Education of China, and funding from the Major Public Health Service Project of the Ministry of Finance and National Health Commission of China.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The project teams of the National Center for Cardiovascular Diseases and the Yale–New Haven Hospital Center for Outcomes Research and Evaluation assisted with project design and operations, and provincial and regional officers and research staff (listed in the Additional Information) assisted with data collection. None of the contributors received financial compensation for their assistance. The authors also wish to thank all study participants.

Additional Information: Members of the Provincial Coordinating Office of the China PEACE MPP Collaborative Group: Beijing Center for Diseases Prevention and Control: Chun Huang, MMed; Zhong Dong, MMed; Bo Jiang, MSc. Tianjin Chest Hospital: Zhigang Guo, MMed; Ying Yi Zhang, MMed. Hebei Center for Diseases Prevention and Control: Jixin Sun, MSc; Yuhuan Liu, MBBS. Shanxi Center for Diseases Prevention and Control: Zeping Ren, MBBS; Yaqing Meng, MBBS. Inner Mongolia Center for Diseases Prevention and Control: Zhifen Wang, MBBS; Yunfeng Xi, MSc. Liaoning Center for Diseases Prevention and Control: Liying Xing, PhD; Yuanmeng Tian, MBBS. Jilin Center for Diseases Prevention and Control: Jianwei Liu, BPH; Yao Fu, MMed; Ting Liu, MMed. Heilongjiang Center for Diseases Prevention and Control: Shichun Yan, MSc; Lin Jin, MBBS. Shanghai Center for Diseases Prevention and Control: Yang Zheng, MSc; Jing Wang, MSc. Jiangsu Center for Diseases Prevention and Control, Zhejiang Provincial People's Hospital: Jing Yan, MMed; Wei Yu, MMed; Xiaoling Xu, MBBS; Shiyun Hu, PhD. Anhui Center for Diseases Prevention and Control: Yeji Chen, BPH; Xiuya Xing, BPH; Luan Zhang, MBBS. Fujian Center for Diseases Prevention and Control: Xin Fang, MBBS; Ze Yang, MBBS. Jiangxi Center for Diseases Prevention and Control: Liping Zhu, MSc; Yan Xu, MSc. Shandong Center for Diseases Prevention and Control: Xiaolei Guo, MSc; Chunxiao Xu, PhD. Henan Center for Diseases Prevention and Control: Gang Zhou, MSc; Lei Fan, MSc; Minjie Qi, MSc. Hubei Center for Diseases Prevention and Control: Shuzhen Zhu, MPH; Junlin Li, MSc; Junfeng Qi, MSc. Hunan Center for Diseases Prevention and Control: Yuelong Huang, MBBS; Li Yin, MSc; Qiong Liu, MBBS. Guangdong Provincial People's Hospital: Yingqing Feng, MD; Jiabin Wang, MBBS; Songtao Tang, College Diploma. The First Affiliated Hospital of Guangxi Medical University: Hong Wen, MD. Health Commission of Hainan: Xuemei Han, BS. Hainan Center for Diseases Prevention and Control: Puyu Liu, MBBS. Chongqing Center for Diseases Prevention and Control: Xianbin Ding, MPH; Jie Xu, MBBS. Sichuan Center for Diseases Prevention and Control: Ying Deng, MSc; Jun He, College Diploma. Guizhou Provincial People's Hospital: Qiang Wu, MD; Gui'e Liu, MBBS; Chenxi Jiang, BS. Yunnan Center for Diseases Prevention and Control: Shun Zha, MBBS; Cangjiang Yang, MSc. Tibet Center for Diseases Prevention and Control: Guoxia Bai, BA; Yue Yu, MBBS; Zongji Tashi, MBBS. Shaanxi Center for Diseases Prevention and Control: Yongbing Cheng, BA; Lin Qiu, MSc; Zhiping Hu, MSc. Gansu Center for Diseases Prevention and Control: Hupeng He, MPH; Jing Zhang, MPH. Qinghai Center for Diseases Prevention and Control: Minru Zhou, MBBS; Xiaoping Li, MPH; Zhihua Xu, MPH. Ningxia Center for Diseases Prevention and Control: Jianhua Zhao, MBBS; Shaoning Ma, MBBS. The First Affiliated Hospital of Xinjiang Medical University: Yitong Ma, MD; Yuchen Zhang, MBBS; Xiang Ma, MBBS. Xinjiang Corps Center for Diseases Prevention and Control: Fanka Li, MSc; Jiacong Shen, MBBS.