Cardiovascular Risk Factor Prevalence and Control by Education Strata in Older Adults in 3 Countries.

Importance: Improvements in cardiovascular disease (CVD) mortality have plateaued in the US and have increased among adults with fewer years of education, a pattern not seen in peer countries. Differences in health system performance managing CVD risk factors may be important in this disparity. Objective: To compare cardiovascular disease risk factor prevalence and management in the US, England, and South Korea over time and by education strata. Design, Setting, and Participants: This secondary analysis of a serial cross-sectional study used nationally representative data from adults 50 years or older from 3 countries during years ranging from 1998 to 2020. Data were analyzed from May 2025 to April 2026. Main Outcomes and Measures: For each risk factor (cholesterol, blood pressure, and diabetes), the share at risk, the care cascade, and the share with uncontrolled risk were measured. Results: This study assessed data from 120 678 adults (mean [SD] age, 63.5 [9.9] years; No. [weighted %], 54 167 [46%] male and 66 511 [54%] female). For each risk factor, the US (n = 27 327) had higher shares at risk than England (n = 41 986) or South Korea (n = 51 365). For example, England had a smaller proportion at risk: 52% in period 4 (mean [SE], 11.1 [1.6] percentage points [pp] lower than in the US). Cholesterol risk in South Korea increased from 46% in 2005 to 2008 to 51% in 2015 to 2020 (P for trend < .001), with levels ultimately similar to England but 12.1 (1.1) pp below the US. US patients at risk were more likely to be aware, treated, and have controlled risk using medications, resulting in more similar uncontrolled risk across countries. Because of higher control of condition risks in the US, the rates of uncontrolled cholesterol risk in the US and England were both 29% (mean [SE] difference, <0.1 [1.5] pp), and the rate uncontrolled in South Korea was 2.2 (1.0) pp higher than the US despite higher at-risk rates. South Korea achieved rapid gains in treatment and control, especially hypertension (6% controlled in 1998-2001 to 42% in 2005-2008, P for trend < .001) and cholesterol (6% controlled in 2005-2008 to 31% in 2015-2020, P for trend < .001). Across countries, risk was higher among adults without a college degree, but control rates among those at risk were similar by education strata. Diabetes risk increased substantially over time (15% to 22% in the US, 9% to 10% in England, and 13% to 19% in South Korea, P for trend < .001), whereas cholesterol and hypertension risk remained stable or decreased. Conclusions and Relevance: In this repeated cross-sectional study of adults aged 50 years and older in the US, England, and South Korea, despite higher baseline risk, the US health system achieved comparable or better performance than England and South Korea in managing CVD risk factors. Differences in risk factor treatment did not explain disparities by country or education strata, suggesting that upstream risk accumulation, rather than care delivery, may be associated with increasing disparities in CVD risk.