This study provides the first macroeconomic assessment of HF in China, projecting a cumulative economic burden of INT$1,001·1 billion (0·256% of GDP) from 2025 to 2035, driven predominantly by indirect costs from labor force attrition (72·1%). Our findings highlight three critical insights: (1) HF’s dual burden among aging and younger populations signals a looming crisis for China’s labor-driven economy; (2) scalable interventions—BNP screening, intensive BP control, and GDMT—could mitigate 12·54% of this burden (INT$123·0 billion saved); and (3) indirect costs dominate HF’s economic impact in China, contrasting sharply with high-income countries where direct medical costs prevail. These results underscore the urgency of integrating HF management into national health agendas, aligning with the Healthy China 2030 initiative and the United Nations Sustainable Development Goals (SDGs).

Globally, HF imposes escalating costs in aging populations, yet China’s economic profile amplifies its vulnerability. In high-income countries, direct medical costs dominate HF-related expenditures (65 – 80% of total burden).^2,23,24 By contrast, China’s indirect costs (72·1%) highlight its reliance on workforce productivity. This pattern aligns with studies of chronic diseases in LMICs, such as COPD and cancer, where indirect costs similarly prevail.^12,13 However, HF’s projected GDP loss (0·365% by 2035) surpasses that of many chronic conditions (e.g., global COPD: 0·111% GDP/year), positioning HF as a macroeconomic priority requiring systemic interventions beyond clinical management.¹²

While global age-standardized CVD prevalence remains stable, HF’s growing burden in China signals an urgent need for life-course prevention.²⁵ By 2050, ischaemic heart disease is projected to cause 20 million cardiovascular deaths globally, with hypertension as the leading modifiable risk factor (18·9 million attributable deaths).²⁵ Despite lower absolute HF risk in younger populations, the stronger association of modifiable risk factors (e.g., hypertension, diabetes) in adults aged 35 – 55 years demands targeted prevention strategies to mitigate productivity losses during peak working years.^26,27

BNP-based screening emerged as the most cost-effective intervention, reducing 8·10% (INT$78·49 billion) of the total HF burden with a cost-benefit ratio of 0·49. This aligns with evidence from the STOP-HF trial, where BNP-guided care reduced left ventricular dysfunction incidence by 41% (OR 0·55; 95% CI 0·37 – 0·82).¹⁸Cost-effectiveness analyses support its scalability.²⁸ However, successful implementation depends on integration into primary care, especially in rural China, where diagnostic tools and specialist care are limited.²⁹ Scaling this intervention requires integrating BNP screening into China’s Essential Public Health Services, prioritizing adults ≥40 years in high-risk regions. Portable BNP devices paired with telemedicine platforms could bridge diagnostic gaps, while training primary care providers in risk stratification would enhance early detection.

Intensive systolic BP control could reduce HF-related economic burdens by 2·74% (INT$27·5 billion), consistent with the SPRINT trial’s 25% HF risk reduction (HR: 0·75; 95% CI: 0·64–0·89).²⁰ The China STEP trial further validated this approach in older adults (target <130 mmHg), significantly lowering cardiovascular events (HR: 0·74; 95% CI: 0·60–0·92), showing a 73% decline in acute HF episodes (HR: 0·27; 95% CI: 0·08 – 0·98).²¹ To offset its 35·0% physical capital depletion (driven by medication costs), subsidizing antihypertensive therapies under national insurance is critical. Systemic barriers—including fragmented medication access and limited BP monitoring infrastructure—constrain scalability. Scalable solutions—such as village doctor-led rural programs, workplace-based BP monitoring, and digital adherence tools—aligned with China’s Essential Public Health Services framework, could bridge implementation barriers, translating clinical success into equitable health and economic outcomes.^30,31

Optimizing GDMT for HFrEF demonstrated balanced efficiency. Despite robust evidence for ACE inhibitors, beta-blockers, and SGLT2 inhibitors, adherence remains suboptimal, with only 6·2% of patients achieving optimal GDMT use within 12 months of diagnosis.^32–35 Significant sex disparities exist, as women receive GDMT less frequently than men.³⁴ Post-discharge mortality in low-income regions correlates with inadequate GDMT prescription, reflecting systemic inequities.³⁶ Scaling China’s Heart Failure Center model—which achieved 80% GDMT adherence through standardized protocols and multidisciplinary care—demonstrates actionable success.¹⁴ A randomized trial confirmed that digital consults improve GDMT optimization, offering scalable solutions to address fragmented access.³⁷ Prioritizing equity-focused policies, multidisciplinary collaboration, AI-driven decision support tools and telehealth consultations is critical to bridging implementation gaps and translating evidence into practice.

HF poses significant clinical and macroeconomic challenges in China. Integrated policies should focus on prevention, workforce protection, and strengthening healthcare systems. Scalable interventions align with the Healthy China 2030 initiative and the Lancet Global Health 2035 Commission’s “50 by 50” goal. Despite progress, universal health coverage lags in preventive care.²⁹ Investments should strengthen primary healthcare infrastructure to address the dual burden of non-communicable diseases and aging.³⁸ Prioritize BNP screening and GDMT for labor force protection, as they are highly cost-effective. Implement hypertension management subsidies to mitigate short-term risks, and leverage AI and telemedicine to standardize treatment and reduce rural-urban disparities. Combining BNP screening and hypertension management could amplify benefits, reducing healthcare expenditures and improving labor force productivity. Joint interventions may lower the total burden compared to BNP screening alone. A national scale-up of BNP screening, especially in rural regions, is essential for maximum impact.

While our study advances the understanding of HF as a macroeconomic challenge, several limitations necessitate cautious interpretation of the findings. First, reliance on GBD data may obscure regional disparities in HF epidemiology and healthcare access. For example, rural-urban gaps in diagnostic capacity — such as limited echocardiography availability in remote areas — were not fully captured, potentially biasing national prevalence projections. Second, the observed wide credible intervals likely reflect compounded uncertainties from sparse subpopulation data (e.g., ethnic minorities, older adults), inherent identifiability constraints in age-period-cohort models, and insufficient smoothing priors amplifying noise in long-term forecasts. Third, fixed treatment costs exclude savings from medical innovations (e.g., SGLT2 inhibitors reducing hospitalizations by 30% in recent trials) and inflationary effects, which may underestimate long-term economic benefits of interventions.³⁸ Fourth, while our analysis focused on HF-specific burdens, cross-disease cost savings from interventions— such as hypertension management reducing stroke incidence — were omitted, narrowing the estimated societal value. Fifth, uniform intervention adoption rates oversimplify implementation realities; for instance, GDMT adherence remains lower in rural versus urban China, yet our model assumed homogeneous scaling. Finally, broader socioeconomic determinants—such as air pollution and healthcare inequities—were omitted, despite evidence linking these factors to HF progression and economic vulnerability.