China’s demographic transition is characterized by a steep and sustained rise in both the proportion and absolute number of older adults [Figure 1A]^[1]. By the end of 2024, the National Bureau of Statistics reported that the population aged ≥ 65 years had reached 220.2 million, representing 15.6% of the total population^[3]. This places China in a stage of deep population aging, commonly defined by a share of adults aged ≥ 65 years exceeding 14%. Projections indicate that this momentum will intensify in the coming decades; the elderly population is expected to peak at approximately 424.5 million by 2058, a figure that dwarfs the elderly populations of many high-income countries combined, underscoring the unprecedented scale of China’s aging transition [Figure 1B]^[1].

The public health significance of this demographic shift lies not only in the number of older adults, but also in the speed with which age-related medical and social care needs are increasing. Older adults have a high prevalence of multimorbidity, including hypertension, diabetes, chronic kidney disease, frailty, cognitive impairment, and CVD, which together increase the complexity and cost of care^[2]. This challenge is amplified by China’s “aging before becoming rich” trajectory, in which population aging has advanced before uniformly strong primary care, long-term care, and social support systems have been fully established. The mismatch between growing geriatric care needs and uneven health-system capacity is particularly pronounced in rural regions^[4].

Population aging in China displays striking geographic and socioeconomic disparities. Rural areas are aging faster than urban centers, largely because of the long-term migration of younger adults to cities for education and employment. This demographic shift has resulted in a relative "hollowing out" of rural communities, leaving many older adults with reduced family support, higher dependency ratios, and fewer nearby caregivers. Recent census data indicate that the old-age dependency ratio in rural areas (28.13%) is nearly double that of urban areas (15.56%)^[5].

These demographic imbalances are compounded by persistent inequities in healthcare workforce distribution and service capacity. Although basic health insurance coverage has expanded substantially, the availability and quality of primary care, cardiology services, emergency transport, rehabilitation, and long-term management remain uneven. Recent statistics revealed that physician density in urban areas is approximately 3.73 per 1,000 population, compared to just 2.42 per 1,000 in rural regions^[6]. This maldistribution limits access not only to routine chronic disease management but also to timely diagnosis, acute cardiovascular care, rehabilitation, and geriatric support services. Consequently, rural older adults may face delayed diagnosis and treatment, which can contribute to avoidable disease progression and widening rural-urban disparities in cardiovascular outcomes^[2,7].

Older adults in rural China face a constellation of health challenges related to socioeconomic disadvantage, limited health literacy, reduced family support, and gaps in health-service infrastructure. Since 2009, rural populations have borne a heavier burden of cardiovascular mortality than urban populations [Figure 2]. In 2021, the age-standardized mortality rate for CVD in rural China was 364.16 per 100,000, exceeding the urban rate of 305.39 per 100,000^[2]. These disparities should be interpreted as the combined result of higher clinical vulnerability, delayed care-seeking, uneven access to prevention and treatment, and limited rehabilitation capacity.

A major contributor to this disparity is the suboptimal management of chronic cardiovascular risk factors. Hypertension prevalence is comparable or slightly higher in rural communities, but awareness, treatment, and control rates remain lower [Table 1]^[2,8,9]. Entrenched beliefs, such as the notion that "absence of symptoms indicates absence of disease," together with concerns about medication costs, continue to undermine long-term adherence^[8]. Furthermore, rural health systems often have limited capacity to manage complex multimorbidity. Despite a reported increase to 7,881 integrated medical and elderly care institutions nationwide by late 2023, their distribution, staffing, quality, and accessibility may remain insufficient relative to the rapidly growing needs of rural older adults^[10]. Without targeted interventions to strengthen rural primary care and chronic disease management, population aging may further widen cardiovascular health inequities between rural and urban China.

Population aging is a central driver of China’s expanding CVD burden. Its effect operates through several overlapping pathways: the growth of the older population, the rising proportion of people in high-risk age groups, cumulative lifetime exposure to risk factors, and biological aging of the cardiovascular system. National data indicate that CVD affects an estimated 330 million people in China, while the incidence of major cardiovascular conditions increases substantially with advancing age^[2]. As shown in Figure 3, older age groups account for a disproportionate share of CVD incidence, with stroke and ischemic heart disease contributing prominently to the age-related increase in disease burden. For example, the incidence of HF increases from 158 per 100,000 person-years in adults aged 25-64 years to 1,655 per 100,000 person-years in those aged ≥ 80 years^[11]. Similar age gradients are observed for ischemic heart disease, stroke, AF, and degenerative valvular disease^[2,12,13].

This age-dependent increase reflects the convergence of biological aging and cumulative lifetime exposure to cardiovascular risk factors. Biological aging contributes to CVD through arterial stiffening, endothelial dysfunction, chronic inflammation, autonomic dysregulation, myocardial fibrosis, and impaired repair mechanisms. These processes predispose older adults to isolated systolic hypertension, AF, degenerative valvular disease, and HF with preserved ejection fraction (HFpEF)^[14]. At the same time, decades of exposure to hypertension, diabetes, dyslipidemia, smoking, unhealthy diet, and physical inactivity accelerate atherosclerosis, vascular remodeling, and myocardial dysfunction. Therefore, aging should be understood as a combined biological and epidemiological process, in which intrinsic cardiovascular vulnerability interacts with accumulated risk exposure to amplify late-life CVD burden.

A key feature of China’s cardiovascular transition is the coexistence of declining age-standardized mortality and rising absolute numbers of CVD deaths^[15]. Improvements in acute care, secondary prevention, and risk-factor management have contributed to reductions in age-standardized mortality. However, these gains have been partly offset by the rapid expansion of the older population, producing a demographic offset effect: fewer deaths occur per age-standardized population, yet more deaths occur in absolute terms. The Report on Cardiovascular Health and Diseases in China estimates that annual CVD deaths now exceed 4.5 million, maintaining CVD as the leading cause of death nationwide^[2].

This pattern has important implications for health-system planning. A declining age-standardized mortality rate may suggest progress in prevention and treatment, but the rising absolute number of deaths indicates a growing demand for emergency care, hospitalization, rehabilitation, long-term medication management, and post-event support. For an aging population characterized by recurrent cardiovascular events, frailty, disability, and multimorbidity, a response centered only on acute hospital care is unlikely to be sufficient. A strategic shift is therefore needed from episodic treatment toward longitudinal risk-factor control, post-event rehabilitation, medication adherence support, and community-based follow-up^[2,16]. Recent modeling evidence further supports the expectation of a sustained cardiovascular burden in China. Using data from the ChinaHEART nationwide cohort and an agent-based model, Wang et al. projected that the annual incidence of CVD would increase from 0.74% in 2021 to 0.97% by 2030, while CVD mortality would rise until 2024 and subsequently stabilize at approximately 0.44% by 2030^[17].

Atherosclerotic cardiovascular disease (ASCVD) remains the dominant component of China’s CVD burden in older adults. CHD and stroke continue to account for a large proportion of cardiovascular deaths, disability, hospitalizations, and long-term care needs. With increasing age, cumulative exposure to hypertension, diabetes, dyslipidemia, smoking, unhealthy diet, and physical inactivity further accelerates atherosclerosis, plaque instability, vascular remodeling, and thromboembolic events. Therefore, ASCVD prevention and treatment should remain the central priority in cardiovascular healthy aging^[15].

At the same time, population aging is increasing the clinical importance of geriatric cardiovascular conditions that often coexist with ASCVD rather than replace it. HF, particularly HFpEF, AF, degenerative valvular disease, frailty-associated cardiovascular decline, and multimorbidity-related treatment complexity are becoming more prominent among older patients^[18,19]. These conditions are closely linked to age-related myocardial fibrosis, arterial stiffening, valvular calcification, autonomic dysregulation, impaired repair capacity, and chronic inflammation^[14,18]. In older adults with CVD, HFpEF, frailty, and multimorbidity frequently co-occur and collectively drive adverse outcomes^[18,19]. Data demonstrate that geriatric vulnerabilities across multiple health domains—medical, mind and emotion, and physical function—commonly overlap in HFpEF, with nearly half of patients exhibiting impairments in all three domains simultaneously^[18]. Moreover, the number of impaired domains exhibits a dose-response relationship with prognosis: impairment of three domains confers a nearly four-fold increase in risk for all-cause hospitalization and mortality, with frailty emerging as the strongest independent prognostic factor^[18]. Polypharmacy affects over 90% of patients with HFpEF, further amplifying the risks of adverse drug events, drug interactions, and cumulative medication burden, particularly in frail individuals^[20,21]. Encouragingly, over 90% of patients with HFpEF report willingness to deprescribe if prompted by their physicians, suggesting that patient-centered medication optimization is feasible in this population^[22].

This intersection of HFpEF, frailty, and multimorbidity not only worsens prognosis but also fundamentally alters treatment logic. Frailty and cognitive impairment compromise patients’ capacity for self-management and medication adherence; consequently, even well-intentioned guideline-directed regimens derived from single-disease trials become difficult to implement in this population, as these trials typically excluded the very patients-those with complex multimorbidity, advanced frailty, or cognitive dysfunction-who are most representative of real-world geriatric cardiology practice^[23]. Meanwhile, polypharmacy exacerbates the risks of falls, delirium, and hospital readmissions, particularly in frail individuals^[22,23]. Consequently, management goals for these patients must shift from event-focused disease control toward integrated strategies that incorporate comprehensive geriatric assessment, deprescribing, and functional preservation^[22-24].

Thus, the aging-related CVD burden in China should not be interpreted as a simple shift from atherosclerotic disease to geriatric cardiovascular syndromes. Rather, it represents a layered transition in which ASCVD remains central, while degenerative CVD, multimorbidity, frailty, and functional decline increasingly shape prognosis, care needs, and health-service utilization. This layered transition is most clearly reflected in several major cardiovascular conditions among older adults, including CHD, stroke, AF, degenerative valvular heart disease (DVHD), and HF. The following section therefore examines these disease-specific burdens and care gaps in greater detail.

CHD has become a leading cause of mortality among older Chinese adults, with prevalence rising sharply with age. Recent estimates indicate that approximately 11.39 million individuals in China are living with CHD, and the mortality burden continues to shift toward rural populations^[2]. In 2021, the age-standardized mortality rate for CHD in rural areas reached 148.19 per 100,000, significantly exceeding the urban rate of 135.08 per 100,000—a disparity that has widened continuously since 2016^[2]. The volume of percutaneous coronary interventions (PCI) has grown robustly; according to the Data Report on PCI in Mainland China 2023, a total of 1,636,055 cases were registered, representing a 26.44% year-on-year growth^[25]; however, this expansion has not fully translated into improved outcomes for rural patients^[26]. Delayed presentation remains a critical bottleneck in acute myocardial infarction care. Symptom-to-door times for acute myocardial infarction (AMI) patients in rural areas are nearly double those of urban centers, reflecting delayed symptom recognition, transport barriers, limited emergency networks, and uneven availability of chest pain centers^[2,27]. For older adults, atypical symptoms, frailty, cognitive impairment, and living alone may further delay treatment seeking. Strengthening county-level chest pain networks, prehospital triage, referral pathways, and post-discharge secondary prevention is therefore essential to reduce avoidable mortality and disability.

Stroke imposes a heavy fatal and disabling burden on older Chinese adults, serving as the primary cause of disability and the second leading cause of death. Latest surveillance data estimate that 17.8 million adults have experienced a stroke, with 3.4 million new incident cases and 2.3 million deaths occurring annually^[28]. China’s stroke profile differs from that of many high-income countries, with a relatively high proportion of hemorrhagic stroke and a large burden attributable to poorly controlled hypertension^[2,28]. Rural stroke mortality (158.63 per 100,000) exceeds urban mortality (129.41 per 100,000), consistent with lower hypertension awareness and control, delayed emergency treatment, and uneven access to rehabilitation. High recurrence rates—reported at 5.6% within one year—highlight persistent gaps in secondary prevention, including blood pressure control, lipid management, antiplatelet or anticoagulant therapy when indicated, smoking cessation, and long-term rehabilitation for the nation's 13 million stroke survivors^[2,28].

AF is a rapidly growing epidemic among older adults, with the national prevalence estimated at 4.87 million cases^[2]. The prevalence exhibits a steep age-dependent rise, escalating from roughly 4% in those aged 75-84 years to nearly 18% in those aged ≥ 95 years^[29]. AF serves as a potent multiplier of cardiovascular risk, increasing the risk of ischemic stroke by 4-5 times and cardiovascular mortality by over three-fold in elderly hypertensive populations^[30]. The interplay between AF and HF is particularly deleterious; approximately 34% of hospitalized HF patients have coexisting AF, a combination that significantly worsens prognosis^[31]. Despite strong evidence supporting oral anticoagulation in eligible patients, anticoagulant therapy remains underused in older Chinese adults with AF, with recent registries indicating that fewer than 40% of eligible elderly patients receive guideline-recommended oral anticoagulation. Barriers include fear of bleeding, limited risk stratification in primary care, underdiagnosis of paroxysmal AF, medication cost, and uncertainty about anticoagulation in frail or multimorbid patients^[30]. Improving AF detection, individualized stroke-bleeding risk assessment, and safe anticoagulation management should be a priority in geriatric cardiovascular care.

As the population ages, the landscape of valvular heart disease in China is transitioning from a predominance of rheumatic etiology to degenerative disease. In patients aged ≥ 75 years, DVHD now accounts for 42.5% of all valvular pathology, with aortic stenosis and mitral regurgitation being the most common lesions^[32,33]. Prevalence studies in southern China suggest that DVHD affects nearly 37% of individuals over age 65, making it a major, often underdiagnosed driver of HF^[33]. The adoption of transcatheter aortic valve replacement (TAVR) has increased rapidly in China, reflecting growing capacity in the care of structural heart disease. According to the National Clinical Research Center for Interventional Medicine (2024), TAVR procedures surged by nearly 40% in 2023, with approximately 14,000 surgeries performed nationwide. This growth underscores the increasing clinical capacity to address degenerative valvular diseases in an aging society^[34]. However, this volume remains insufficient relative to the estimated 1.5 million elderly patients suffering from severe, symptomatic aortic stenosis in China. This discrepancy highlights a substantial treatment gap, as the current annual procedure volume covers less than 1% of the potential candidate pool, emphasizing the urgent need for expanded access to transcatheter therapies, particularly within regional medical centers^[35,36].

HF represents the final battleground of cardiovascular defense in the elderly. A 2025 analysis from the Global Burden of Disease Study estimates that 14.3 million people in China are now living with HF, a staggering increase driven by population aging and improved survival from ischemic heart disease^[37]. The prevalence rises exponentially with age, reaching 7.55% in individuals aged ≥ 80 years^[31]. The phenotype of HF is also shifting: HFpEF has emerged as the dominant form in older adults, accounting for over 50% of cases in community settings^[31]. The prognosis remains poor, with 1-year mortality rates for hospitalized patients approaching 17.4% and 5-year mortality exceeding 50%^[31]. Addressing this burden requires a paradigm shift toward comprehensive management that targets not just the heart, but the multimorbid frailty syndrome typical of these patients.

Cardiovascular healthy aging in China requires a coordinated prevention and care framework that spans population-level risk-factor control, evidence-based clinical prevention and treatment, community-based delivery models, and geriatric-psychosocial support. At the population level, priority should be given to scalable interventions such as dietary sodium reduction, culturally adapted physical activity, environmental risk mitigation, and age-friendly community design. At the clinical level, strategies should include vaccination for vulnerable patients, simplified pharmacotherapy, evidence-informed adjunctive traditional Chinese medicine, and frailty-aware use of guideline-directed therapies [Table 2]. Because older adults frequently live with multimorbidity, frailty, cognitive impairment, polypharmacy, and functional limitations, interventions should be evaluated not only by disease-specific outcomes but also by adherence, safety, equity, functional recovery, and preservation of intrinsic capacity. For China, effective strategies must be affordable, culturally acceptable, and deliverable through rural, community, and primary-care systems.

Psychological distress, depression, loneliness, and social isolation are increasingly recognized as important modifiers of cardiovascular risk and prognosis. Recent authoritative reviews, including the seminal Scientific Statement from the American Heart Association (2021) and updated consensus documents, stated that these factors may influence CVD through behavioral pathways, such as medication nonadherence and physical inactivity, as well as biological pathways, including autonomic dysregulation, inflammation, and neuroendocrine activation^[63]. Evidence from the China Health and Retirement Longitudinal Study (CHARLS) further quantifies this risk, identifying that older adults with persistent depressive symptom trajectories face a 1.7-fold increased risk of incident CVD^[64].

These findings support the integration of geriatric and psychosocial assessment into cardiovascular care for older adults. In primary care and community settings, screening for frailty, depression, cognitive impairment, loneliness, medication burden, and functional limitation may help identify patients at high risk of poor adherence, hospitalization, disability, and incomplete recovery. Interventions may include behavioral support, medication review, social prescribing, caregiver engagement, referral to mental health services, and linkage with community activity programs. Rather than creating a separate care pathway, geriatric-psychosocial integration should be embedded into routine chronic disease management and post-event follow-up.

Together, dietary sodium reduction, culturally adapted physical activity, vaccination for vulnerable patients, simplified pharmacotherapy, evidence-informed adjunctive TCM, frailty-aware guideline-directed treatment, and digitally supported primary care provide a practical framework for cardiovascular healthy aging in China. Rather than being defined by technological sophistication, these strategies collectively reflect an implementation-oriented approach that emphasizes scalability, affordability, cultural acceptability, and applicability within both rural and urban health systems.

Moreover, China's deep-rooted cultural tradition of filial piety and community mutual aid provides a unique social and ethical foundation for aging in place. When effectively integrated with structured community health services—including village doctor-led chronic disease management, home-based blood pressure monitoring, and community exercise programs—this cultural infrastructure can strengthen the delivery of cardiovascular preventive care, enhance treatment adherence, and provide psychosocial support for older adults living with CVD.

The central policy implication is a shift from fragmented, hospital-centered treatment toward integrated, community-based management. This shift aligns with the WHO Integrated Care for Older People framework, which emphasizes preservation of intrinsic capacity and functional ability. For China, implementation should prioritize rural primary care, risk-factor control, post-event rehabilitation, medication adherence, psychological support, and coordination between medical care, public health, and social services^[65]. However, both the strength of evidence and the feasibility of implementation vary across strategies. Dietary sodium substitution, the polypill strategy, influenza vaccination in high-risk cardiovascular patients, village doctor-led task-sharing for hypertension control, and selected TCM formulations as adjunctive therapy are supported by adequately powered, multicenter randomized trials with hard clinical endpoints or validated surrogate outcomes [Table 2]. In contrast, TCEs and geriatric-psychosocial integration are currently supported by meta-analyses of smaller trials and longitudinal cohort studies, and would benefit from larger-scale confirmatory research [Table 3]. In addition, the feasibility of these strategies varies substantially. Dietary sodium substitution and TCEs are the most readily scalable, given their low cost, cultural acceptance, and minimal infrastructure requirements. Village doctor-led task-sharing and digital decision support are also feasible but demand sustained investment in training, supervision, and digital infrastructure. Influenza vaccination and the polypill strategy, despite strong evidence, face barriers including vaccine hesitancy, out-of-pocket costs, and limited regulatory approval for certain fixed-dose combinations in China. Frailty-aware guideline-directed therapy requires geriatric competencies that remain scarce in rural primary care. Geriatric-psychosocial integration faces the greatest implementation challenges, including shortages in mental health workforce, lack of validated screening tools for older Chinese populations, and weak referral pathways between medical and social services. Future implementation should therefore be accompanied by pragmatic trials, real-world evaluation, and health-economic assessment.

The cardiovascular burden of population aging extends beyond clinical complexity to impose substantial demands on the healthcare workforce across multiple disciplines, including cardiology, geriatrics, rehabilitation nursing, and primary care. This challenge is particularly acute in China, where the healthcare delivery system has long been hospital-centric and specialized-care oriented, with limited capacity for long-term chronic disease management and geriatric-psychosocial support^[65]. The rapid growth of older populations with multimorbidity, frailty, and functional limitations will require not only more cardiologists but also a larger number of geriatricians, rehabilitation therapists, community health nurses, and trained long-term care workers, all of which are professions currently in critical shortage nationwide^[66].

National data indicate a persistent maldistribution of health workers between urban and rural areas, with physician density in urban China (3.73 per 1,000 population) substantially exceeding that in rural regions (2.42 per 1,000) in 2021^[6]. This urban-rural gap is even wider for specialist services: cardiologists, geriatricians, and rehabilitation professionals are concentrated in tertiary hospitals in large cities, leaving county-level and township facilities understaffed for the escalating burden of cardiovascular aging^[2,25,26]. The shortage of geriatric competencies is particularly concerning. Most front-line healthcare providers in primary care and long-term care settings lack formal training in geriatric assessment, frailty management, polypharmacy review, and psychosocial support—skills that are essential for managing older adults with complex CVD^[67].

Moreover, the long-term care workforce—which is crucial for post-stroke rehabilitation, HF self-management support, and functional preservation—remains grossly insufficient relative to the needs of China's aging population^[67]. It is estimated that China has only approximately 300,000 registered long-term care workers nationwide to support over 40 million older adults with disabilities^[67]. The unattractive career prospects of this profession, including low wages, heavy workloads, limited career development opportunities, and low social recognition, have led to low recruitment and high turnover rates, further constraining the system's capacity to support older adults with cardiovascular disability^[67].

To address these workforce shortages, China will need a multipronged strategy that includes: (1) expanding training programs in geriatric cardiology and geriatric medicine at both undergraduate and postgraduate levels^[67]; (2) task-sharing with trained village doctors and community health workers for routine risk-factor management and post-discharge follow-up, as exemplified by CRHCP^[59,60]; (3) strengthening financial and career incentives to attract and retain health workers in rural and primary-care settings^[67]; and (4) integrating digital clinical decision support and telehealth to extend specialist expertise to under-resourced areas, which can partially mitigate workforce shortages while preserving quality^[61]. Without substantial investments in workforce development, the growing cardiovascular burden among older adults—particularly in rural China—is likely to widen existing disparities in access, quality, and outcomes^[68].

In summary, although our proposed framework is broadly consistent with existing national policy directions such as Healthy China 2030, the tiered delivery system, Long-Term Care Insurance pilots, and Internet+Health initiatives, a substantial implementation gap remains. Most current programs are pilot-based, unevenly distributed across regions, and have not yet been scaled nationally^[67,68]. Our framework contributes by explicitly linking these policies through a coordinated, patient-centered care continuum that spans primary prevention, acute care, rehabilitation, and long-term support, with particular emphasis on rural-equity considerations that are often under-addressed in national guidelines.