Original Investigation | Cardiology

Prevalence of Dyslipidemia and Availability of Lipid-Lowering Medications

Among Primary Health Care Settings in China
Yuan Lu, ScD; Haibo Zhang, MD; Jiapeng Lu, PhD; Qinglan Ding, PhD; Xinyue Li, PhD; Xiaochen Wang, PhD; Daqi Sun, MS; Lingyi Tan, MS; Lin Mu, MD;
Jiamin Liu, MD; Fang Feng, MD; Hao Yang, BS; Hongyu Zhao, PhD; Wade L. Schulz, MD, PhD; Harlan M. Krumholz, MD; Xiangbin Pan, MD; Jing Li, MD, PhD;
for the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project Collaborative Group

Abstract Key Points

Question What is the prevalence of
IMPORTANCE Dyslipidemia, the prevalence of which historically has been low in China, is emerging
dyslipidemia in Chinese adults and what
as the second leading yet often unaddressed factor associated with the risk of cardiovascular
are the treatment and control rates of
diseases. However, recent national data on the prevalence, treatment, and control of dyslipidemia
elevated low-density lipoprotein
are lacking.
cholesterol in both primary and
secondary prevention populations?
OBJECTIVE To assess the prevalence, treatment, and control of dyslipidemia in community
residents and the availability of lipid-lowering medications in primary care institutions in China. Findings In this cross-sectional study of
2 314 538 community residents, 33.8%
DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the China- had dyslipidemia, 3.2% had established
PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) Million Persons Project, which atherosclerotic cardiovascular disease
enrolled 2 660 666 community residents aged 35 to 75 years from all 31 provinces in China between (ASCVD), and 10.2% had high risk of
December 2014 and May 2019, and the China-PEACE primary health care survey of 3041 primary ASCVD; 26.6% of those with ASCVD and
care institutions. Data analysis was performed from June 2019 to March 2021. 42.9% of those at high risk of ASCVD
achieved low-density lipoprotein
EXPOSURES Study period. cholesterol control targets. Statins were
available in 49.7% of the primary care
MAIN OUTCOMES AND MEASURES The main outcome was the prevalence of dyslipidemia, which institutions surveyed, with the lowest
was defined as total cholesterol greater than or equal to 240 mg/dL, low-density lipoprotein availability in rural village clinics.
cholesterol (LDL-C) greater than or equal to 160 mg/dL, high-density lipoprotein cholesterol (HDL-C)
Meaning These findings suggest that
less than 40 mg/dL, triglycerides greater than or equal to 200 mg/dL, or self-reported use of lipid-
dyslipidemia has become a major public
lowering medications, in accordance with the 2016 Chinese Adult Dyslipidemia Prevention Guideline.
health problem in China and is often
inadequately treated and uncontrolled.
RESULTS This study included 2 314 538 participants with lipid measurements (1 389 322 women
[60.0%]; mean [SD] age, 55.8 [9.8] years). Among them, 781 865 participants (33.8%) had
dyslipidemia. Of 71 785 participants (3.2%) who had established atherosclerotic cardiovascular + Supplemental content
disease (ASCVD) and were recommended by guidelines for lipid-lowering medications regardless of Author affiliations and article information are
LDL-C levels, 10 120 (14.1%) were treated. The overall control rate of LDL-C (ⱕ70 mg/dL) among listed at the end of this article.

adults with established ASCVD was 26.6% (19 087 participants), with the control rate being 44.8%
(4535 participants) among those who were treated and 23.6% (14 552 participants) among those not
treated. Of 236 579 participants (10.2%) with high risk of ASCVD, 101 474 (42.9%) achieved LDL-C
less than or equal to 100 mg/dL. Among participants with established ASCVD, advanced age (age
65-75 years, odds ratio [OR], 0.63; 95% CI, 0.56-0.70), female sex (OR, 0.56; 95% CI, 0.53-0.58),
lower income (reference category), smoking (OR, 0.89; 95% CI, 0.85-0.94), alcohol consumption
(OR, 0.87; 95% CI, 0.83-0.92), and not having diabetes (reference category) were associated with
lower control of LDL-C. Among participants with high risk of ASCVD, younger age (reference
category) and female sex (OR, 0.58; 95% CI, 0.56-0.59) were associated with lower control of LDL-C.

(continued)

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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 JAMA Network Open | Cardiology Dyslipidemia and Availability of Lipid-Lowering Medications in Chinese Primary Health Care Settings

Abstract (continued)

Of 3041 primary care institutions surveyed, 1512 (49.7%) stocked statin and 584 (19.2%) stocked
nonstatin lipid-lowering drugs. Village clinics in rural areas had the lowest statin availability.

CONCLUSIONS AND RELEVANCE These findings suggest that dyslipidemia has become a major
public health problem in China and is often inadequately treated and uncontrolled. Statins were
available in less than one-half of the primary care institutions. Strategies aimed at detection,
prevention, and treatment are needed.

JAMA Network Open. 2021;4(9):e2127573. doi:10.1001/jamanetworkopen.2021.27573

Introduction
China is in the midst of an epidemiological transition in which cardiovascular diseases (CVDs) have
replaced infectious diseases as the leading cause of death.1 Currently, CVD in China accounts for more
than 40% of the causes of death.2 There are concerns that dyslipidemia, the prevalence of which
historically was low in China, is emerging as the second leading yet often unaddressed factor
associated with the risk of CVD.3
Recent national studies4,5 have assessed the overall prevalence of dyslipidemia and
achievement of low-density lipoprotein cholesterol (LDL-C) lowering targets in the Chinese
population. However, they did not assess the treatment rate and control rate of elevated LDL-C in
both primary and secondary prevention populations. In addition, data are lacking on the availability
of lipid-lowering medications in primary care institutions, which play an important role in preventing
and managing chronic diseases. Assessing the prevalence, treatment, and control patterns of
dyslipidemia and associated characteristics in community residents can help identify subgroups of
individuals who will be the target population for interventions to reduce cardiovascular risk.
Moreover, assessing the availability of lipid-lowering medications in primary care institutions is
critical for assisting the development of policies to mitigate the burden of dyslipidemia.
The China-PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) Million Persons
Project (MPP), a large-scale population-based screening project, is an ideal platform to study
dyslipidemia in Chinese adults, given the large size of this data set and the recruitment of participants
at the community level. Accordingly, in this cross-sectional study, we leveraged the China-PEACE
MPP and a national survey of primary care institutions to describe the prevalence, treatment, and
control of dyslipidemia and the availability of lipid-lowering medications in primary care institutions.

Methods
Participants and Study Design
The central ethics committee at the China National Center for Cardiovascular Disease and the
institutional review board at Yale University approved this project. All enrolled participants provided
written informed consent. This study follows the Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.6

China-PEACE MPP
From December 2014 to May 2019, we used a purposive sampling method to select 189 sites (114
rural counties, 75 urban districts) across all 31 provinces in China.7 Sites were selected purposefully
to reflect the diversity in geographical distribution, economic development, and population structure
across the country (see details in eAppendix 1 in Supplement 1). At each site, participants were
recruited by local staff via extensive publicity campaigns on television and in newspapers and were
enrolled if they were aged 35 to 75 years and currently residents in the selected region. Participants

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were then screened for high risk of CVD using measurements of blood pressure, blood lipids, blood
glucose, height, and weight; a questionnaire assessing cardiovascular-related health status was also
administered. Of the 2 660 666 participants enrolled, 322 814 (12.1%) were excluded from this
analysis because they lacked fasting blood lipid measurements or had implausible lipid values, and
23 314 (0.8%) were excluded because of missing data for other covariates (eFigure 1 in
Supplement 1).

China-PEACE Primary Health Care Survey

From November 2016 to May 2017, we conducted a nationwide survey in 3529 primary care
institutions in the China-PEACE MPP network.8 These institutions included 188 community health
centers and 490 community health stations from the urban areas, and 286 township health centers
and 2565 village clinics from the rural areas. In China, primary health care services are provided by
community health centers and community health stations (1 level below) in urban areas and by
township health centers and village clinics (1 level below) in rural areas. The distribution of sampled
primary care institutions across rural and urban areas reflected the national ratio of rural to urban
institutions.9

Data Collection and Variables

At the initial screening of China-PEACE MPP, participants underwent a lipid blood test performed by
a rapid lipid analyzer using whole blood samples (CardioChek PA Analyzer; Polymer Technology
Systems). Participants were considered in a fasting state if their last meals were taken more than 8
hours before. Total cholesterol (TC), triglycerides (TG), and high-density lipoprotein cholesterol
(HDL-C) were measured. LDL-C was calculated with the Friedewald equation after excluding
participants with TG greater than 400 mg/dL (to convert TG to millimoles per liter, multiply
by 0.0113).
Dyslipidemia was defined as TC greater than or equal to 240 mg/dL (to convert to millimoles
per liter, multiply by 0.0259), LDL-C greater than or equal to 160 mg/dL (to convert to millimoles per
liter, multiply by 0.0259), HDL-C less than 40 mg/dL (to convert to millimoles per liter, multiply by
0.0259), or TG greater than or equal to 200 mg/dL, or self-reported use of lipid-lowering
medications, in accordance with the 2016 Chinese Adult Dyslipidemia Prevention Guideline.10 We
used the same definition among secondary prevention population to be consistent with previous
national studies in China.4,5 Participants were considered as being treated for dyslipidemia if they
reported using lipid-lowering medication (Western medicines or traditional Chinese medication
[TCM]) within the last 2 weeks. Control of LDL-C was defined on the basis of atherosclerotic
cardiovascular disease (ASCVD) risk stratification in accordance with the Chinese guideline (see
details in eAppendix 2 in Supplement 1).10 Specifically, participants were considered as achieving
LDL-C control targets if they had established ASCVD (ie, coronary heart disease or stroke) and LDL-C
less than or equal to 70 mg/dL, or if they had an estimated 10-year ASCVD risk of greater than or
equal to 10% and LDL-C less than or equal to 100 mg/dL, or if they had an estimated 10-year ASCVD
risk of less than 10% and LDL-C less than or equal to130 mg/dL.
Information on the participants’ sociodemographic characteristics, health behaviors, medical
history, and cardiovascular risk factors was recorded during in-person interviews as described
elsewhere.7 Height and weight were collected using standard protocols, and body mass index was
calculated by dividing the weight in kilograms by the square of height in meters. Obesity was defined
as a body mass index of at least 28, in accordance with the recommendations of the Working Group
on Obesity in China.11
The availability of lipid-lowering medications, including statins, nonstatins, and TCMs (see a
complete list in eAppendix 3 in Supplement 1), was obtained from each primary care institution
participating in the China-PEACE primary health care survey. We collected lists of medications in
stock at the time of the survey from each participating primary care institution. For each medication
on the list, we collected its generic name, brand name, and dosage.8

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Statistical Analysis
We described the prevalence of dyslipidemia in the overall study population and stratified by ASCVD
risk. Because the indication of lipid-lowering therapy is based on ASCVD risk in current clinical
guidelines,10 we described the treatment and control rates of LDL-C among participants with
established ASCVD and high risk of ASCVD, respectively. Both groups were recommended by clinical
guidelines to achieve LDL-C control targets to lower the risk of ASCVD. In a sensitivity analysis, we
determined the age-standardized prevalence of dyslipidemia by adjusting observation weights to
match the age and sex distributions in the 2010 Chinese Census.12
We developed multivariable mixed models with a logit link function and township-specific
random intercepts (to account for geographical autocorrelation) to identify individual characteristics
associated with the prevalence of dyslipidemia among all study participants and the control of LDL-C
among participants with established and high risk of ASCVD, respectively. Finally, we assessed the
availability of lipid-lowering medications in primary care institutions by calculating the proportion of
participating institutions with a specific type of lipid-lowering medication in stock. We examined the
availability by type of primary care institutions and region.
All analyses were conducted with R statistical software version 3.33 (R Project for Statistical
Computing). All statistical testing was 2-sided, at a significance level of P < .05. Data analysis was
performed from June 2019 to March 2021.

Results
Prevalence of Dyslipidemia Overall and in Subtypes
Our final sample of China-PEACE MPP included 2 314 538 participants (1 389 322 women [60.0%];
mean [SD] age, 55.8 [9.8] years) (eFigure 1 in Supplement 1), 1 369 160 of whom (59.2%) were from
rural areas (Table 1). Overall, 781 865 participants (33.8%) had dyslipidemia, 71 785 (3.2%) had
experienced prior cardiovascular events, and 236 579 (10.2%) had high risk of ASCVD.
The prevalence of high TC was 7.1% (164 201 participants), that of high LDL-C was 4.0% (91 683
participants), that of high TG was 16.9% (390 244 participants), and that of low HDL-C was 15.6%
(361 395 participants). Low HDL-C and high TG levels were the most common lipid abnormalities
(46.2% [361 395 participants] and 49.9% [390 244 participants] of individuals with dyslipidemia,
respectively), with mean (SD) HDL-C of 55.9 (15.9) mg/dL and mean (SD) TG of 139.9 (69.3) mg/dL
(eFigure 2 in Supplement 1 and Figure 1). Using the 2010 Chinese Census data, we reported the age-
and sex-standardized rate of overall dyslipidemia to be 34.1%.
In multivariable regression analysis, we identified that advanced age, female sex, nonfarmer
occupation, higher income, higher education level, smoking, alcohol consumption, prior
cardiovascular events, diabetes, and obesity were associated with higher risk of TC greater than or
equal to 240 mg/dL, LDL-C greater than or equal to 160 mg/dL, or TG greater than or equal to 200
mg/dL. However, younger age, male sex, nonfarmer occupation, higher income, higher education
level, smoking, no alcohol consumption, prior cardiovascular events, diabetes, and obesity were
associated with higher risk of HDL-C less than 40 mg/dL (Table 2).

Treatment and Control of LDL-C Among Participants With Established and High Risk
of ASCVD
A total of 71 785 participants had established ASCVD and were recommended for lipid-lowering
medications regardless of LDL-C levels, of whom 10 120 (14.1%) were treated and 61 665 (85.9%)
were untreated with any lipid-lowering medications. The control rate of LDL-C (ⱕ70 mg/dL) among
adults with established ASCVD was 26.6% (19 087 participants), with the control rate being 44.8%
(4535 participants) among those who were treated and 23.6% (14 552 participants) among those
who were untreated (Figure 2).
A total of 236 579 participants had high risk of ASCVD, of whom 101 474 (42.9%) achieved LDL-C
control targets (ⱕ100 mg/dL). Among 135 105 participants who had high risk of ASCVD and LDL-C

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 JAMA Network Open | Cardiology Dyslipidemia and Availability of Lipid-Lowering Medications in Chinese Primary Health Care Settings

greater than 100 mg/dL, 6044 (4.5%) were treated with lipid-lowering medications (Figure 2). Among
769 722 participants with low or moderate risk of ASCVD, the overall treatment and control rates of
LDL-C were 2.2% (17 087 participants) and 55.7% (428 588 participants), respectively.
In multivariable regression analysis, we identified that advanced age (age 65-75 years, odds
ratio [OR], 0.63; 95% CI, 0.56-0.70), female sex (OR, 0.56; 95% CI, 0.53-0.58), lower income

Table 1. Characteristics of Participants in China Patient-Centered Evaluative Assessment of Cardiac Events

Million Persons Project

Participants, No. (%)

Characteristics Overall With dyslipidemia Without dyslipidemia
Total 2 314 538 (100.0) 781 865 (33.8) 1 532 673 (66.2)
Age, y
35-44 346 630 (15.0) 104 166 (13.3) 242 464 (15.8)
45-54 729 548 (31.5) 243 426 (31.1) 486 122 (31.7)
55-64 727 975 (31.5) 260 271 (33.3) 467 704 (30.5)
65-75 510 385 (22.1) 174 002 (22.3) 336 383 (21.9)
Sex
Male 925 216 (40.0) 349 896 (44.8) 575 320 (37.5)
Female 1 389 322 (60.0) 431 969 (55.2) 957 353 (62.5)
Urbanity
Urban 945 378 (40.8) 340 014 (43.5) 605 364 (39.5)
Rural 1 369 160 (59.2) 441 851 (56.5) 927 309 (60.5)
Region
Eastern 872 317 (37.7) 303 185 (38.8) 569 132 (37.1)
Western 783 088 (33.8) 262 460 (33.6) 520 628 (34.0)
Central 659 133 (28.5) 216 220 (27.7) 442 913 (28.9)
Education
Primary school or lower 976 520 (42.2) 307 353 (39.3) 669 167 (43.7)
Middle school 755 316 (32.6) 257 997 (33.0) 497 319 (32.4)
High school 368 971 (15.9) 136 236 (17.4) 232 735 (15.2)
College or above 182 218 (7.9) 69 669 (8.9) 112 549 (7.3)
Unknowna 31 513 (1.4) 10 610 (1.4) 20 903 (1.4)
Annual household income, yuanb
<10 000 447 743 (19.3) 140 275 (17.9) 307 468 (20.1)
10 000-50 000 1 275 123 (55.1) 427 161 (54.6) 847 962 (55.3)
>50 000 383 064 (16.6) 144 180 (18.4) 238 884 (15.6)
Unknowna 208 608 (9.0) 70 249 (9.0) 138 359 (9.0)
Marital status
Married 2 151 920 (93.0) 726 565 (92.9) 1 425 355 (93.0)
Widowed, separated, 135 022 (5.8) 46 019 (5.9) 89 003 (5.8)
divorced, single
Unknowna 27 596 (1.2) 9281 (1.2) 18 315 (1.2)
Health insurance status
Insured 2 262 681 (97.8) 764 283 (97.8) 1 498 398 (97.8)
Uninsured 14 978 (0.6) 5261 (0.7) 9717 (0.6)
Unknowna 36 879 (1.6) 12 321 (1.6) 24 558 (1.6)
Medical history
Myocardial infarction 16 920 (0.7) 8717 (1.1) 8203 (0.5) a
Unknown reflects that the participants either
Stroke 56 920 (2.5) 26 545 (3.4) 30 375 (2.0) refused to answer the question or did not know
Cardiovascular disease risk factor the answer.
b
Diabetes 150 433 (6.5) 74 262 (9.5) 76 171 (5.0) The average conversion rate in 2019 was 6.91 yuan to
$1.00 US.
Current smoker 443 055 (19.1) 171 938 (22.0) 271 117 (17.7)
c
Current drinker 544 902 (23.5) 197 074 (25.2) 347 828 (22.7) Obesity is defined as a body mass index (weight in
c
kilograms divided by height in meters squared)
Obesity 362 392 (15.7) 170 600 (21.8) 191 792 (12.5)
greater than or equal to 28.

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 JAMA Network Open | Cardiology Dyslipidemia and Availability of Lipid-Lowering Medications in Chinese Primary Health Care Settings

(reference category), smoking (OR, 0.89; 95% CI, 0.85-0.94), alcohol consumption (OR, 0.87; 95%
CI, 0.83-0.92), and no diabetes (reference category) were associated with lower control of LDL-C
among participants with established ASCVD. Younger age (reference category) and female sex (OR,
0.58; 95% CI, 0.56-0.59) were associated with lower control of LDL-C among participants with high
risk of ASCVD (Table 3).

Availability of Lipid-Lowering Medications in Primary Care Institutions

Of the 3529 primary care institutions surveyed, 3041 with completed medication availability data
were included in the final analysis. These institutions included 145 community health centers and 384
community health stations from the urban areas, 243 township health centers and 2269 village
clinics from the rural areas (eTable 1 in Supplement 1).
Of 3041 primary care institutions included in the analysis, 1512 (49.7%) stocked statins, 584
(19.2%) stocked nonstatins, and 467 (15.4%) stocked lipid-lowering TCM. Xuezhikang, the only TCM
that had evidence of secondary prevention for CVD, was stocked in 311 primary care institutions
(10.2%). Among the 4 types of institutions, community health centers had the highest statin
availability (114 centers [78.6%]), whereas village clinics had the lowest statin availability (991 clinics
[43.7%]) (eFigure 3 in Supplement 1). Simvastatin was the most commonly stocked statin (1422
clinics [46.8%]), followed by atorvastatin (808 clinics [26.6%]), and rosuvastatin (559 clinics
[18.4%]) (eTable 2 in Supplement 1).

Figure 1. Prevalence of Abnormal Lipid Profiles Among China Patient-Centered Evaluative Assessment
of Cardiac Events Million Persons Project Participants, by Age and Sex

TC ≥240 mg/dL HDL-C <40 mg/dL Lipid-lowering medication

LDL-C ≥160 mg/dL TG >200 mg/dL Total dyslipidemia

Men
50

40
Percentage

30

20

10

0
35-44 45-54 55-64 65-75
Age, y

Women
50

40
Percentage

30

20
HDL-C indicates high-density lipoprotein cholesterol
(to convert to millimoles per liter, multiply by 0.0259);
10 LDL-C, low-density lipoprotein cholesterol (to convert
to millimoles per liter, multiply by 0.0259); TC, total
0 cholesterol (to convert to millimoles per liter, multiply
0 35-44 45-54 55-64 65-75 by 0.0259); TG, triglycerides (to convert to millimoles
Age, y per liter, multiply by 0.0113).

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 Table 2. Prevalence of Different Components of Dyslipidemia and Associated Characteristics

Overall dyslipidemia TC ≥240 mg/dL LDL-C ≥160 mg/dL HDL-C <40 mg/dL TG ≥200 mg/dL
Prevalence, Prevalence, Prevalence, Prevalence, Prevalence,
Characteristic % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a
Age, y
35-44 29.95 (29.79-30.10) 1 [Reference] 3.10 (3.04-3.16) 1 [Reference] 1.75 (1.70-1.79) 1 [Reference] 18.64 (18.51-18.78) 1 [Reference] 14.71 (14.58-14.83) 1 [Reference]
45-54 32.69 (32.58-32.80) 1.17 (1.15-1.18) 6.17 (6.11-6.22) 2.14 (2.09-2.20) 3.40 (3.36-3.44) 2.11 (2.04-2.18) 16.36 (16.27-16.44) 0.89 (0.88-0.91) 17.45 (17.36-17.53) 1.21 (1.19-1.23)
55-64 34.10 (33.99-34.21) 1.21 (1.20-1.22) 8.80 (8.73-8.87) 3.23 (3.15-3.31) 5.01 (4.95-5.06) 3.20 (3.10-3.30) 14.90 (14.82-14.99) 0.76 (0.75-0.77) 17.88 (17.79-17.97) 1.21 (1.19-1.23)
65-75 31.86 (31.73-31.99) 1.07 (1.06-1.09) 8.51 (8.43-8.58) 3.24 (3.15-3.33) 4.73 (4.67-4.79) 3.13 (3.02-3.23) 14.12 (14.02-14.22) 0.67 (0.66-0.68) 15.85 (15.75-15.95) 1.05 (1.03-1.06)
Sex
JAMA Network Open | Cardiology

Male 36.67 (36.57-36.77) 1 [Reference] 4.06 (4.02-4.10) 1 [Reference] 2.62 (2.59-2.65) 1 [Reference] 24.35 (24.26-24.44) 1 [Reference] 16.60 (16.52-16.68) 1 [Reference]
Female 29.80 (29.72-29.88) 0.74 (0.73-0.74) 9.06 (9.01-9.11) 2.83 (2.78-2.88) 4.84 (4.81-4.88) 2.16 (2.12-2.21) .01 (9.96-10.06) 0.30 (0.29-0.30) 16.97 (16.91-17.03) 1.16 (1.15-1.17)
Marital status

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Not 32.27 (32.01-32.52) 1 [Reference] 9.50 (9.34-9.66) 1 [Reference] 4.98 (4.86-5.1) 1 [Reference] 12.32 (12.14-12.50) 1 [Reference] 17.67 (17.47-17.88) 1 [Reference]
married
Married 32.56 (32.50-32.62) 0.99 (0.98-1.01) 6.92 (6.88-6.95) 0.92 (0.90-0.94) 3.90 (3.87-3.92) 0.95 (0.93-0.98) 15.93 (15.88-15.98) 1.07 (1.05-1.09) 16.80 (16.74-16.85) 0.99 (0.97-1.00)
Annual
household
income,
yuanb
≤50 000 31.83 (31.76-31.90) 1 [Reference] 6.95 (6.92-6.99) 1 [Reference] 3.78 (3.75-3.81) 1 [Reference] 15.16 (15.11-15.22) 1 [Reference] 16.56 (16.50-16.62) 1 [Reference]
>50 000 35.79 (35.63-35.94) 1.07 (1.06-1.08) 7.59 (7.50-7.67) 1.02 (1.00-1.04) 4.64 (4.57-4.70) 1.06 (1.04-1.09) 18.07 (17.95-18.2) 1.08 (1.06-1.09) 18.53 (18.41-18.66) 1.07 (1.05-1.08)
Education
level
Lower than 32.17 (32.11-32.24) 1 [Reference] 7.23 (7.19-7.26) 1 [Reference] 4.01 (3.98-4.04) 1 [Reference] 15.14 (15.09-15.19) 1 [Reference] 16.73 (16.68-16.78) 1 [Reference]
college

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College or 36.80 (36.57-37.03) 1.07 (1.06-1.09) 5.32 (5.21-5.42) 1.00 (0.98-1.03) 3.37 (3.28-3.45) 1.05 (1.02-1.08) 22.15 (21.96-22.35) 1.09 (1.07-1.11) 18.34 (18.16-18.52) 1.07 (1.05-1.09)
above
Occupation
Not farmer 34.92 (34.83-35.00) 1 [Reference] 7.33 (7.28-7.37) 1 [Reference] 4.26 (4.22-4.29) 1 [Reference] 17.58 (17.51-17.65) 1 [Reference] 18.07 (18.00-18.13) 1 [Reference]
Farmer 29.88 (29.79-29.97) 0.87 (0.86-0.88) 6.76 (6.72-6.81) 0.93 (0.91-0.95) 3.62 (3.58-3.65) 0.89 (0.87-0.92) 13.68 (13.61-13.74) 0.84 (0.83-0.86) 15.43 (15.36-15.5) 0.88 (0.87-0.9)
Health
insurance
status
Insured 32.54 (32.48-32.60) 1 [Reference] 7.08 (7.05-7.12) 1 [Reference] 3.96 (3.94-3.99) 1 [Reference] 15.69 (15.64-15.74) 1 [Reference] 16.86 (16.81-16.91) 1 [Reference]
Uninsured 34.78 (33.69-35.86) 1.02 (0.96-1.09) 7.35 (6.76-7.95) 0.94 (0.84-1.05) 3.85 (3.41-4.29) 0.93 (0.82-1.07) 16.42 (15.58-17.27) 1.05 (0.97-1.13) 18.59 (17.71-19.48) 1.00 (0.92-1.07)
CVD risk
factor
Current 37.89 (37.74-38.03) 1.21 (1.2-1.23) 4.49 (4.42-4.55) 1.03 (1.00-1.05) 2.79 (2.74-2.84) 1.05 (1.02-1.08) 24.68 (24.55-24.81) 1.30 (1.29-1.32) 17.87 (17.76-17.99) 1.16 (1.15-1.18)
smoker
Current 35.01 (34.88-35.14) 0.94 (0.93-0.95) 5.70 (5.64-5.76) 1.19 (1.17-1.21) 3.30 (3.25-3.35) 1.1 (1.08-1.13) 19.44 (19.33-19.55) 0.76 (0.75-0.77) 18.04 (17.94-18.15) 1.13 (1.12-1.15)
drinker
Diabetes 44.65 (44.39-44.91) 1.60 (1.58-1.62) 9.47 (9.32-9.62) 1.13 (1.11-1.15) 5.37 (5.25-5.48) 1.11 (1.08-1.14) 21.08 (20.87-21.29) 1.53 (1.51-1.56) 26.37 (26.14-26.6) 1.74 (1.71-1.76)
Obesityc 45.21 (45.05-45.38) 1.95 (1.94-1.97) 8.27 (8.18-8.37) 1.12 (1.10-1.14) 4.69 (4.62-4.76) 1.14 (1.12-1.16) 23.26 (23.12-23.40) 2.05 (2.03-2.07) 26.07 (25.93-26.22) 2.01 (1.99-2.03)
Prior CVD 38.94 (38.58-39.31) 1.15 (1.13-1.17) 7.71 (7.51-7.91) 1.00 (0.97-1.03) 4.52 (4.37-4.68) 1.08 (1.04-1.13) 19.78 (19.49-20.08) 1.24 (1.21-1.27) 20.90 (20.6-21.20) 1.08 (1.06-1.11)

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(continued)
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 Table 2. Prevalence of Different Components of Dyslipidemia and Associated Characteristics (continued)

Overall dyslipidemia TC ≥240 mg/dL LDL-C ≥160 mg/dL HDL-C <40 mg/dL TG ≥200 mg/dL
Prevalence, Prevalence, Prevalence, Prevalence, Prevalence,
Characteristic % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a
Geographical
region
Western 32.58 (32.47-32.69) 1 [Reference] 5.24 (5.19-5.29) 1 [Reference] 2.94 (2.90-2.98) 1 [Reference] 18.92 (18.83-19.01) 1 [Reference] 15.52 (15.44-15.60) 1 [Reference]
Central 31.7 (31.58-31.81) 0.92 (0.90-0.95) 6.46 (6.40-6.53) 1.41 (1.34-1.48) 3.19 (3.14-3.23) 1.36 (1.28-1.43) 14.41 (14.32-14.50) 0.71 (0.68-0.74) 17.69 (17.59-17.78) 1.05 (1.02-1.08)
Eastern 33.16 (33.06-33.26) 0.98 (0.96-1.01) 9.19 (9.13-9.25) 1.90 (1.82-1.98) 5.47 (5.42-5.52) 2.09 (1.99-2.20) 13.84 (13.76-13.91) 0.77 (0.75-0.8) 17.36 (17.28-17.44) 0.95 (0.93-0.98)
b
Abbreviations: CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density The average conversion rate in 2019 was 6.91 yuan to $1.00 US.
c
JAMA Network Open | Cardiology

lipoprotein cholesterol; OR, odds ratio; TC, total cholesterol; TG, triglycerides. Obesity is defined as a body mass index (weight in kilograms divided by height in meters squared) greater than
SI conversion factors: To convert HDL-C to millimoles per liter, multiply by 0.0259; LDL-C to millimoles per liter, or equal to 28.
multiply by 0.0259; TC to millimoles per liter, multiply by 0.0259; TG to millimoles per liter, multiply by 0.0113.
a
ORs were derived from multivariable regression models and adjusted for all sociodemographic and clinical

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characteristics included in Table 1.

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Figure 2. Prevalence, Treatment, and Low-Density Lipoprotein Cholesterol (LDL-C) Control of Participants With High or Extremely High Risk
of Atherosclerotic Cardiovascular Disease (ASCVD)

A Prevalence of low, moderate, high, and extremely high risk Low risk High risk
of ASCVD among all participants
Moderate risk Extremely high risk
Men Women
30 30

25 25

20 20

Percentage
Percentage

15 15

10 10

5 5

0 0
35-44 45-54 55-64 65-75 35-44 45-54 55-64 65-75
Age, y Age, y

B Treatment and control of LDL-C levels among participants

with extremely high risk of ASCVD Treatment Control
Men Women
40 40

30 30
Percentage

Percentage

20 20

10 10

0 0
35-44 45-54 55-64 65-75 35-44 45-54 55-64 65-75
Age, y Age, y

C Treatment and control of LDL-C levels among participants

with high risk of ASCVD Treatment Control
Men Women
60 60

50 50

40 40
Percentage

Percentage

30 30

20 20

10 10

0 0
35-44 45-54 55-64 65-75 35-44 45-54 55-64 65-75
Age, y Age, y

Panel A shows prevalence of low, medium, high and extremely high risk of ASCVD among participants with high risk of ASCVD. Participants with extremely high risk of ASCVD
all study participants. Panel B shows treatment and control of LDL-C among participants were those with established ASCVD.
with extremely high risk of ASCVD. Panel C shows treatment and control of LDL-C among

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 Table 3. Treatment Rates and Control Rate of LDL-C and Associated Characteristics by ASCVD Risk Groups

Treatment of LDL-C Control of LDL-C

Participants with high risk of ASCVD Participants with established ASCVD Participants with high risk of ASCVD Participants with established ASCVD
Prevalence, Prevalence, Prevalence, Prevalence,
Characteristic % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a % (95% CI) OR (95% CI)a
Age, y
35-44 4.51 (4.09-4.94) 1 [Reference] 7.88 (6.73-9.03) 1 [Reference] 40.24 (39.23-41.25) 1 [Reference] 31.76 (29.76-33.75) 1 [Reference]
45-54 4.72 (4.54-4.89) 1.10 (0.99-1.24) 12.79 (12.17-13.4) 1.47 (1.24-1.75) 43.55 (43.14-43.96) 1.15 (1.09-1.22) 27.75 (26.93-28.57) 0.74 (0.66-0.83)
55-64 5.80 (5.65-5.95) 1.34 (1.20-1.50) 14.13 (13.71-14.54) 1.47 (1.25-1.74) 41.84 (41.52-42.17) 1.11 (1.06-1.17) 25.4 (24.88-25.92) 0.62 (0.56-0.70)
65-75 6.27 (6.09-6.44) 1.49 (1.33-1.66) 14.73 (14.32-15.14) 1.46 (1.23-1.72) 43.88 (43.52-44.24) 1.19 (1.13-1.26) 26.52 (26.01-27.04) 0.63 (0.56-0.70)
JAMA Network Open | Cardiology

Sex
Male 5.02 (4.89-5.15) 1 [Reference] 14.96 (14.58-15.35) 1 [Reference] 49.81 (49.51-50.11) 1 [Reference] 30.99 (30.5-31.49) 1 [Reference]
Female 6.19 (6.05-6.33) 1.30 (1.25-1.35) 13.04 (12.69-13.39) 0.86 (0.82-0.91) 36.47 (36.19-36.74) 0.58 (0.56-0.59) 22.22 (21.79-22.65) 0.56 (0.53-0.58)
Marital status

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Not married 5.89 (5.54-6.25) 1 [Reference] 13.35 (12.49-14.20) 1 [Reference] 41.95 (41.21-42.7) 1 [Reference] 24.29 (23.21-25.37) 1 [Reference]
Married 5.63 (5.53-5.73) 1 (0.93-1.07) 14.05 (13.78-14.33) 1.08 (0.99-1.17) 42.95 (42.74-43.16) 1 (0.96-1.03) 26.69 (26.34-27.04) 1.02 (0.95-1.09)
Annual household income,
yuanb
≤50 000 5.02 (4.91-5.13) 1 [Reference] 12.81 (12.53-13.09) 1 [Reference] 43.05 (42.81-43.29) 1 [Reference] 26.41 (26.04-26.78) 1 [Reference]
>50 000 7.91 (7.65-8.16) 1.35 (1.28-1.41) 21.61 (20.79-22.44) 1.25 (1.17-1.34) 42.94 (42.47-43.41) 1.01 (0.98-1.04) 27.4 (26.51-28.3) 1.09 (1.03-1.17)
Education level
Lower than college 5.47 (5.37-5.57) 1 [Reference] 13.63 (13.36-13.89) 1 [Reference] 42.71 (42.49-42.92) 1 [Reference] 26.37 (26.03-26.72) 1 [Reference]
College or above 7.96 (7.53-8.39) 1.36 (1.27-1.46) 19.39 (18.22-20.55) 1.29 (1.18-1.42) 45.34 (44.55-46.13) 0.96 (0.92-1.00) 27.78 (26.46-29.1) 1.04 (0.95-1.13)
Occupation
Not farmer 6.65 (6.52-6.78) 1 [Reference] 16.71 (16.33-17.08) 1 [Reference] 42.92 (42.65-43.19) 1 [Reference] 25.27 (24.84-25.71) 1 [Reference]

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Farmer 4.21 (4.09-4.34) 0.68 (0.65-0.71) 10.59 (10.25-10.93) 0.72 (0.67-0.76) 42.74 (42.43-43.06) 0.98 (0.95-1.01) 27.88 (27.38-28.38) 1.00 (0.95-1.06)
Health insurance status
Insured 5.63 (5.54-5.73) 1 [Reference] 13.98 (13.72-14.24) 1 [Reference] 42.86 (42.65-43.06) 1 [Reference] 26.44 (26.11-26.77) 1 [Reference]
Uninsured 4.19 (2.64-5.74) 0.76 (0.51-1.14) 8.23 (3.94-12.51) 0.68 (0.37-1.25) 37.73 (33.99-41.48) 0.91 (0.75-1.10) 22.78 (16.24-29.33) 1.09 (0.69-1.71)
Cardiovascular disease
risk factor
Current smoker 5.02 (4.86-5.18) NA 13.22 (12.68-13.77) 0.87 (0.82-0.93) 49.21 (48.84-49.57) NA 28.87 (28.14-29.6) 0.89 (0.85-0.94)
Current drinker 5.66 (5.48-5.84) NA 14.70 (14.15-15.26) 0.95 (0.89-1.01) 47.17 (46.79-47.55) NA 27.28 (26.58-27.98) 0.87 (0.83-0.92)
Diabetes 7.19 (7.05-7.33) NA 22.36 (21.58-23.13) 1.68 (1.59-1.78) 52.9 (52.62-53.17) NA 29.22 (28.37-30.07) 1.22 (1.15-1.28)
Obesity 6.94 (6.73-7.15) NA 16.66 (16.06-17.26) 1.23 (1.17-1.30) 44.60 (44.19-45) NA 25.99 (25.28-26.7) 0.99 (0.95-1.04)
Geographical region
Western 4.23 (4.07-4.38) 1 [Reference] 12.10 (11.65-12.55) 1 [Reference] 48.05 (47.66-48.44) 1 [Reference] 28.74 (28.12-29.37) 1 [Reference]
Eastern 5.23 (5.05-5.40) 1.35 (1.28-1.43) 12.48 (12.08-12.87) 1.24 (1.12-1.37) 45.24 (44.84-45.63) 0.77 (0.74-0.81) 26.60 (26.07-27.13) 0.87 (0.81-0.93)
Central 6.73 (6.58-6.88) 1.54 (1.47-1.62) 17.51 (17.00-18.01) 1.81 (1.65-1.99) 38.24 (37.94-38.54) 0.58 (0.55-0.61) 24.13 (23.57-24.7) 0.76 (0.71-0.82)

Abbreviations: ASCVD, atherosclerotic cardiovascular disease; LDL-C, Low-density lipoprotein cholesterol; NA, not applicable; OR, odds ratio.
a
ORs were derived from multivariable regression models and adjusted for all sociodemographic and clinical characteristics included in Table 1. We did not include smoking, alcohol use, obesity, and diabetes for model among

September 29, 2021

participants with high risk of ASCVD because these variables were used to calculate risk of ASCVD.
b
The average conversion rate in 2019 was 6.91 yuan to $1.00 US.
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 JAMA Network Open | Cardiology Dyslipidemia and Availability of Lipid-Lowering Medications in Chinese Primary Health Care Settings

Discussion
This large, national cross-sectional study found that dyslipidemia is highly prevalent in China but
commonly undertreated and uncontrolled. Even among people with established ASCVD and high risk
of ASCVD, only 26.6% and 42.9%, respectively, achieved LDL-C control targets. Moreover, statins,
the evidence-based lipid-lowering medications recommended by the guideline, are not available in
almost one-half of the primary care institutions, with the lowest availability in rural village clinics.
Our study extends the literature in several important ways. First, our study is one of the largest
and most recent studies to show the nationwide characteristics of the dyslipidemia epidemic in
China. Although the prevalence of dyslipidemia was consistent with previous studies and
meta-analyses,4,5,13-15 the large size of our study allowed us to draw robust conclusions across a wide
variety of subgroups. Our results reveal that dyslipidemia has become a major factor associated with
the risk of CVD in China overall and across diverse population subgroups, suggesting that a national
approach is warranted to mitigate dyslipidemia and the resulting burden of CVD. In addition, low
HDL-C and high TG levels have become the dominant components of dyslipidemia, which are
different than the high TC and LDL-C levels found in the US and European countries.16-18 This finding
calls for attention to HDL-C and TG management in addition to LDL-C control emphasized in most of
the current guidelines. Icosapent ethyl, a new TG-lowering drug, has been shown to have a
substantial benefit with respect to major adverse cardiovascular events in the recent REDUCE-IT
trial19,20 and was granted priority review by the US Food and Drug Administration.21 China may
consider adopting new treatments to control TG as they become available. Moreover, lifestyle
modifications endorsed by guidelines to improve HDL-C and TG may be particularly relevant to the
Chinese population and should be promoted.10
Second, we showed that despite the low prevalence of increased LDL-C, the absolute number
of people with elevated LDL-C is still large, yet its treatment and control are far from optimal. In
particular, for patients with established ASCVD, statins were recommended as first-line medications
for risk reduction irrespective of LDL-C levels according to the secondary prevention guidelines.22,23
However, only 14.1% of patients with established ASCVD in our study were treated with lipid-
lowering medications and the use of statins was even lower. We further identified that younger age
and female sex were associated with lower control of LDL-C among people with high risk of ASCVD,
indicating that preventive interventions to control LDL-C should be targeted to these subgroups for
optimal outcomes.
Third, to our knowledge, this study is the first national study to assess the availability of lipid-
lowering medications in primary care institutions from all 31 provinces in China. Previous studies were
limited to specific regions, populations, or data sources.13,24-29 We found that evidence-based
medications, such as statins, were stocked in only one-half of the primary care institutions. One of
the commonly stocked TCMs, xuezhikang, was endorsed by the Chinese guideline10 because studies
showed it had a lipid-lowering effect similar to that of statins.30-32 However, the safety and efficacy
of other TCMs stocked in primary care institutions were unclear and need additional evaluation.
Our study found that the associations between different forms of dyslipidemia and some risk
factors, including age, sex, and alcohol consumption, may be different. The differential association
may be associated with different sex hormones in men and women. It has been shown that
menopause leads to changes in lipid profile through reducing HDL-C and increasing TC, TG, and
LDL-C.33 Our study also supports a previous study34 reporting that lower alcohol consumption was
associated with higher HDL-C levels. Studies35 have shown that alcohol reduces the activity of
cholesterol ester transformation from HDL to atheromatic molecules, subsequently increased the
circulating levels of HDL-C.
Our study has important policy implications. Despite historically low lipid levels in the Chinese
population, marked changes in diet and physical activity, especially increased dietary energy intake
and sedentary behaviors, has increased the rate of dyslipidemia, a factor substantially associated
with the risk of CVD.36-38 If China seeks to mitigate increasing prevalence of CVD, reducing

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 JAMA Network Open | Cardiology Dyslipidemia and Availability of Lipid-Lowering Medications in Chinese Primary Health Care Settings

dyslipidemia is a potential good target. An important step is to increase the capacity of primary care
institutions to screen, diagnose, and treat dyslipidemia in community residents. The Chinese health
reform in 2009 emphasized the role of primary health care as the gatekeeper to health care
system.39 However, routine screening programs for blood lipid levels are still not provided in primary
care institutions, limiting the detection and treatment of dyslipidemia. In addition, it is important to
ensure that effective lipid-lowering medications are available in primary care institutions where basic
medical services are provided. The marked deficiencies in statin availability at primary care
institutions are not consistent with the health needs of the people and have implications for patients’
health. The 2018 National Essential Medicines List40 has included more evidence-based lipid-
lowering medications and could facilitate the provision of these medications; however, this program
is in the early stages of implementation. Finally, effective community-based prevention strategies
that promote lifestyle modification (eg, regular physical activity and dietary improvement) are
needed to control dyslipidemia, particularly HDL-C and TG levels, in the Chinese population.

Limitations
Our study had some limitations. First, our study used a purposeful, rather than random, sampling
strategy. However, participants from all ethnic groups across all provinces in China were included,
and the ratios of participants in rural to urban areas in each province were comparable to national
census data. Compared with the age and sex distribution of national census data, this study has more
women and more adults in the older age group, which may result in overestimating the prevalence
of dyslipidemia. However, we calculated the age- and sex-standardized estimates for dyslipidemia
prevalence according to the 2010 Chinese Census data, and the estimates closely resemble our main
results. In addition, use of lipid-lowering medications was self-reported, which could be subject to
recall bias. We asked a subset of participants to bring in the bottle of mediations for validation
purpose and found that self-reported data may tend to underestimate the overall treatment rate,
because some participants who received treatment could not recall the name of lipid-lowering
medications. Nevertheless, ongoing rates of dyslipidemia in those taking lipid-lowering medications
reflect that it is likely few were taking effective medications. Furthermore, we defined diabetes
according to physician diagnosis only, which tends to underestimate the overall prevalence of
diabetes given the large proportion of people with undiagnosed diabetes. Because people with
diabetes are considered at high risk of ASCVD and require lipid-lowering therapy for risk reduction,
our analysis tends to underestimate the proportion of participants with high risk of ASCVD.

Conclusions
In conclusion, the findings of this study suggest that dyslipidemia has become a major public health
problem in China and is often inadequately treated and uncontrolled. Statins were available in less
than one-half of the primary care institutions, with the lowest availability in rural village clinics. A
focus on lipid management, in addition to other emerging risk factors, including hypertension,
smoking, and air quality, represents immense opportunities for China to stem an increasing
population threat of cardiovascular diseases.

ARTICLE INFORMATION
Accepted for Publication: June 25, 2021.
Published: September 29, 2021. doi:10.1001/jamanetworkopen.2021.27573
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Lu Y et al.
JAMA Network Open.
Corresponding Authors: Xiangbin Pan, MD, National Clinical Research Center for Cardiovascular Diseases, NHC
Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular

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 JAMA Network Open | Cardiology Dyslipidemia and Availability of Lipid-Lowering Medications in Chinese Primary Health Care Settings

Disease Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd,
Beijing 100037, People’s Republic of China (xiangbin428@hotmail.com); 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, 167 Beilishi Rd, Beijing 100037, People’s Republic of China (jing.li@
fwoxford.org).
Author Affiliations: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Section of
Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
(Y. Lu, Ding, Mu, Schulz, Krumholz); National Clinical Research Center for Cardiovascular Diseases, National Health
Commission 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, Beijing, China (Zhang, J. Lu, Liu, Feng, Yang, Pan, J. Li); Department of
Biostatistics, Yale University, New Haven, Connecticut (X. Li, Wang, Sun, Tan, Zhao); Fuwai Hospital Chinese
Academy of Medical Sciences, Shenzhen, China (J. Li).
Author Contributions: Dr Li had full access to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis. Drs Lu and Zhang contributed equally as co–first authors. Drs
Krumholz, Pan, and Li contributed equally as co–senior authors.
Concept and design: Y. Lu, Zhang, Mu, Feng, Pan, J. Li.
Acquisition, analysis, or interpretation of data: Y. Lu, Zhang, J. Lu, Ding, X. Li, Wang, Sun, Tan, Mu, Liu, Yang, Zhao,
Schulz, Krumholz, J. Li.
Drafting of the manuscript: Y. Lu, Zhang, Ding, X. Li, Sun.
Critical revision of the manuscript for important intellectual content: Y. Lu, J. Lu, Ding, Wang, Tan, Mu, Liu, Feng,
Yang, Zhao, Schulz, Krumholz, Pan, J. Li.
Statistical analysis: J. Lu, X. Li, Wang, Sun, Tan, Mu, Zhao.
Obtained funding: J. Li.
Administrative, technical, or material support: Y. Lu, Zhang, Mu, Liu, Feng, Schulz.
Supervision: Feng, Pan, J. Li.
Conflict of Interest Disclosures: Dr Y. Lu reported receiving grants from the National Heart, Lung, and Blood
Institute outside the submitted work. Dr Ding reported receiving grants from Marion General Hospital (HRSA-19-
018) outside the submitted work. Dr Mu reported receiving personal fees from HealthCare Royalty Partners
outside the submitted work. Dr Schulz reported receiving personal fees from the National Center for
Cardiovascular Disease, HugoHealth, and Refactor Health outside the submitted work. Dr Krumholz reported
receiving personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, Siegfried &
Jensen Law Firm, Arnold & Porter Law Firm, Martin/Baughman Law Firm, F-Prime, and National Center for
Cardiovascular Diseases, Beijing; being a cofounder of HugoHealth and Refactor Health; receiving contracts from
Centers for Medicare & Medicaid Services through Yale New Haven Hospital to develop and maintain measures of
hospital performance; and receiving grants from Medtronic, the Food and Drug Administration, Johnson &
Johnson, and Shenzhen Center for Health Information outside the submitted work. Dr J. Li reported receiving
grants from Ministry of Science and Technology of the People’s Republic of China during the conduct of the study
and receiving nonfinancial support from Amgen, Sanofi, University of Oxford, AstraZeneca, and Lilly outside the
submitted work. No other disclosures were reported.
Funding/Support: This work was supported by the National Key Research and Development Program from the
Ministry of Science and Technology of China (grant 2018YFC1311205), the Major Public Health Service Project from
the Ministry of Finance and National Health and Family Planning Commission of China, and the 111 Project from the
Ministry of Education of China (grant B16005).
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.
Group Members: China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project
Collaborative Group members are listed in Supplement 2.
Additional Contributions: We thank Lixin Jiang, MD, PhD, for designing and implementing the China PEACE
Million Persons Project. We thank all the participants for their participation. We thank all provincial and regional
officers and research staff in all 31 provinces for their collection of data and biospecimens. We appreciate the
contributions made by project teams at the National Center for Cardiovascular Diseases in the realms of project
design and operations; in particular, Yang Yang, MBA, Jingwei Yang, MSSc, Jianlan Cui, MSPM, Wei Xu, MPH, Bo Gu,

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MEc, Xi Li, MD, PhD, Chaoqun Wu, MS, and Hui Zhong BS, assisted with data collection. They were not
compensated beyond their normal salaries.

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SUPPLEMENT 1.
eAppendix 1. Detailed Information About Sampling Selection in China-PEACE Million Persons Project
eAppendix 2. List of Lipid-Lowering Medications
eAppendix 3. Classification of Low, Medium, High, and Extremely High Risk of ASCVD According to Chinese
Guideline
eTable 1. Characteristics of Primary Care Institutions Included in the Analysis
eTable 2. Individual Drugs Available in the Primary Care Institutions
eFigure 1. Flowchart of Study Participant Selection in China-PEACE Million Persons Project
eFigure 2. Distribution of Lipid Profile Among Participants in China-PEACE Million Persons Project
eFigure 3. Availability of Lipid-Lowering Medications (Statin, Non-Statin, Traditional Chinese Medicine) Among
3,041 Primary Care Institutions, by Type of Site and Economic Region

SUPPLEMENT 2.
China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project (China-PEACE
MPP) Collaborative Group Members

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