The Role of Urban Built Environment in Enhancing Cardiovascular Health in Chinese Cities: A Systematic Review

Abstract

Urban built environments in Chinese cities have increasingly been shown to not only influence human health outcomes but also promote sustainable urban development pathways. These health and sustainability advantages have had significant implications for cardiovascular disease (CVD) prevention and management. CVD represents a growing public health challenge in China’s rapidly urbanizing contexts. However, people living in poorly designed built environments receive less attention and tend to experience disproportionate cardiovascular health risks due to limited access to health-promoting environmental features. Therefore, this systematic review emphasizes the role of urban built environments in shaping cardiovascular health outcomes. Previous studies have highlighted the importance of spatial indicators, such as the Normalized Difference Vegetation Index (NDVI), green space ratio, walkability, and public open space, in influencing cardiovascular health. Using various common cardiovascular diseases and their risk factors as outcome measures, this review conducted a comprehensive literature search across CNKI, Web of Science, Scopus, and PubMed. The search aimed to identify studies examining the associations between urban built environments and cardiovascular health outcomes, in order to synthesize and present the research progress in this field. Through this review, we find that physical activity serves as the key mediating mechanism linking built environment characteristics to cardiovascular outcomes. Based on this finding, this review argues that urban built environment design and sustainable urbanism should prioritize cardiovascular health considerations in the planning process, as this health-oriented approach has the greatest potential for advancing public health resources and moving cities closer to being truly sustainable and health-promoting environments.

1. Introduction

Against the backdrop of China’s rapid urbanization over the past four decades, cardiovascular disease (CVD) has emerged as the leading cause of mortality among China’s population [1,2], making Chinese urban contexts a critical focus for built environment and health research. Medical research has identified poorly designed built environments as a significant contributor to this public health crisis [3,4,5], highlighting the urgent need for “preventive design” strategies in residential communities [6,7,8]. The ongoing processes of industrialization and urban expansion have reshaped the spatial configuration of cities and altered their socioeconomic and ecological environments, profoundly affecting residents’ lifestyles, mental health, and exposure to physical and chemical stressors [9,10,11,12].

The World Health Organization (WHO) has promoted the development of healthy cities and communities [13,14], recognizing health-oriented urban design as a vital strategy in the prevention of non-communicable diseases, including CVD. While urban planning initially arose in the 19th century to combat public health epidemics, it has since evolved into a distinct academic discipline [15,16]. Over the past 15 years, there has been a renewed global interest in healthy urban planning, largely driven by the increasing prevalence of chronic diseases [17,18]. A growing body of evidence links the built environment to a wide range of health outcomes, including health behaviors [19,20], traffic-related injuries [21], noise [22], air pollution [23], and food access [24]. In the 20th century, scientific consensus established obesity, hypertension, and diabetes as primary risk factors for CVD [25].

The built environment exerts a profound and multifaceted influence on the prevalence of CVD, primarily through indirect pathways involving behavior [24,26]. In recent decades, however, researchers have increasingly turned their attention to how community-level built environment features influence these underlying risk factors [16,27]. From a behavioral standpoint, several factors have been identified as direct contributors to the rising incidence of heart disease [18,28,29,30], including insufficient physical activity, unhealthy dietary patterns (high fat and salt intake), alcohol consumption, smoking, and sleep deprivation. Environmental exposures such as air and noise pollution [31,32], and socioeconomic disparities [33], further exacerbate cardiovascular risks.

Although genetic predisposition remains a fundamental determinant of heart disease [34,35], the interaction between urbanization, environmental stressors, and health outcomes remains an area of ongoing academic debate. This study, while acknowledging these complexities, focuses on the linear relationship between urban form and cardiovascular disease in Chinese cities to investigate specific influencing mechanisms relevant to China’s unique urbanization trajectory.

Current evidence suggests that the built environment affects CVD through four primary pathways: health-related behaviors [20,30], environmental exposures [11,36,37], mental health [12,38], and socioeconomic conditions [38,39,40]. Regular physical activity, for example, enhances cardiopulmonary function and reduces the risks of hypertension, obesity, and diabetes. Conversely, residing in areas with high concentrations of PM2.5 and NO₂—such as near industrial zones or major traffic corridors—can trigger inflammatory responses and oxidative stress [41]. Prolonged exposure to noise pollution has also been linked to autonomic nervous system dysregulation, contributing to hypertension [42], arrhythmias [43], and insomnia [44]. Furthermore, densely populated and socioeconomically disadvantaged neighborhoods often impose psychological stress, increasing susceptibility to depression and anxiety [45,46]. Vulnerable populations living in low-resource environments tend to face disproportionately higher CVD risks due to cumulative disadvantages [33,47].

Empirical studies have underscored the significant role of urban physical attributes in shaping cardiovascular health, such as green spaces [48,49], land use mix [37], transportation networks [3], and pollution levels [50,51,52,53]. However, CVD is not typically caused by any single spatial factor in isolation. Rather, complex mediating mechanisms bridge the built environment and cardiovascular outcomes. A critical gap in the literature lies in the insufficient identification and synthesis of these mediating factors, as well as the lack of integrative frameworks that comprehensively evaluate the built environment through their lens.

Directly redesigning urban environments to reduce CVD prevalence poses significant implementation challenges. A more pragmatic approach involves elucidating the mediating mechanisms by which built environments influence cardiovascular health. This review seeks to identify the most salient mediating pathways by synthesizing existing literature through keyword analysis. Targeted interventions aimed at these mechanisms may provide an effective strategy to indirectly mitigate heart disease risks via spatial optimization. This paper addresses two key questions:

(1) What are the primary mediating factors linking the built environment to cardiovascular disease in Chinese cities?

(2) Based on available narrative evidence from systematic literature review, what built environment factors show consistent associations with CVD outcomes, and what are the key evidence gaps preventing definitive comparative assessment?

By addressing these questions, this review contributes to a more comprehensive and interdisciplinary understanding of the relationship between urban form and cardiovascular health. It also identifies existing research gaps and proposes strategic insights for health-oriented urban planning and policy development.

2. Materials and Methods

2.1. Definition

According to the World Health Organization (WHO), CVD (https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) (accessed on 5 July 2025)) refers to a group of disorders involving the heart and blood vessels, including coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic and congenital heart diseases, deep vein thrombosis, and pulmonary embolism. The key behavioral risk factors for CVD—such as unhealthy diet, physical inactivity, smoking, and harmful alcohol consumption—are widely recognized as major contributors to the development of heart disease and stroke. Among environmental determinants, air pollution and noise have also been identified as significant risk factors [31,42]. These behavioral and environmental risks often manifest physiologically through elevated blood pressure [54], blood glucose levels [55], lipid disorders [56], and conditions such as overweight and obesity [3,48,55].

Physical activity (https://www.who.int/news-room/fact-sheets/detail/physical-activity (accessed on 5 July 2025)), as a central protective factor, encompasses all forms of bodily movement-including leisure-time exercise, active transportation, occupational activities, and domestic tasks. Both moderate- and vigorous-intensity physical activities have been shown to produce substantial health benefits. Common and accessible forms of physical activity-such as walking, cycling, wheeled mobility, recreational sports, and active play-can be performed across a range of skill levels, making them suitable and beneficial for the general population.

The urban built environment has emerged as a central focus of multidisciplinary research spanning urban studies, public health, and related fields, particularly in efforts to identify determinants of cardiovascular health and to inform the development of public health policies [20,36,40,57,58]. The term “built environment” (https://www.healthandenvironment.org/resources/environmental-hazards/exposure-sources/built-environment (accessed on 5 July 2025)) typically refers to the human-made surroundings that result from production and everyday life activities. It encompasses a wide range of spatial scales—from entire urban settlements to individual buildings—and includes the physical settings in which people live, work, and engage in daily routines. Key components of the built environment include green spaces, transportation infrastructure, and public service facilities, all of which shape patterns of mobility, physical activity, and access to essential resources.

2.2. Search Approach

This study employed a combination of bibliometric analysis and systematic literature review to ensure comprehensive, accurate, and well-interpreted data collection. A subject-based search was conducted across several core academic databases, including CNKI (China National Knowledge Infrastructure), Web of Science (WOS), Scopus, and PubMed, to capture a broad and representative sample of relevant research.

Based on the conceptual framework outlined above, the search strategy utilized keywords such as “cardiovascular”, “CVD”, “urban planning”, “urban design”, “morbidity”, “built environment”, and “heart”. These terms were selected to encompass multiple relevant disciplines, including geography, public health, environmental behavior, and health and safety sciences. Through a systematic screening process, the literature most relevant to the research topic—particularly recent and influential studies—was identified and synthesized to inform the review.

The inclusion of CNKI (China National Knowledge Infrastructure) is particularly justified for this China-focused study, as it provides essential access to Chinese-language literature offering unique insights into China’s urban health challenges, local policy contexts, and region-specific urban planning practices that may not be comprehensively covered in international databases. This comprehensive database approach ensures that both international perspectives and China-specific research findings are adequately represented in our systematic review.

Detailed search strategies and methodologies for each database are provided in Appendix A.

2.3. Screening and Selection Process

At the initial stage of data collection, a total of 1491 English-language articles and 12 Chinese-language articles were retrieved. During the secondary screening phase, we excluded studies that were unrelated to disease types, not focused on urban contexts, inconsistent with the research framework, or had inaccessible full-text articles. The remaining literature was required to meet the following inclusion criteria: (1) The article must contain at least one of the following keywords: “built environment”, “urban planning”, “urban design” or “city”. (2) The article employed a quantitative, qualitative, or mixed-methods approach, addressing the research topic from different analytical dimensions.

Meanwhile, the exclusion criteria were defined as follows: (1) Articles that did not directly address CVD or its risk factors in relation to the built environment, urban settings, or community contexts, (2) Non-empirical studies, including literature reviews, theoretical discussions, opinion pieces, and editorials—only original research based on empirical data was considered, (3) The publication is a conference proceeding, a master’s dissertation, or a chapter from an edited volume, (4) Articles for which the full text was unavailable.

As a result, 987 English-language articles were retained from the WOS, Scopus, and PubMed databases and 5 Chinese-language articles. An additional 83 relevant studies were reviewed to provide a more comprehensive explanation of the mediating mechanisms. After combining results across databases and removing duplicates, a total of 1035 documents were identified for bibliometric analysis using VOSviewer (version 1.8.0). Among these, 914 papers met our stricter inclusion criteria for detailed content analysis and systematic evidence synthesis, while the remaining 121 documents provided supplementary context for keyword analysis and trend identification. Figure 1 illustrates the process of literature identification, screening, and inclusion.

2.4. Result and Analysis

This study aims to systematically review the impact of built environment elements on residents’ cardiovascular health, with the objective of presenting the current research landscape—including major perspectives, directions, and focal areas—and of synthesizing existing findings to elucidate the mediating factor through which various components of the built environment influence cardiovascular health. The visualization of 1035 articles, generated using VOSviewer, is shown in Figure 2.

Based on the keyword co-occurrence analysis, the terms “built environment”, “human”, “physical activity” and “cardiovascular disease” exhibit large node sizes, indicating that they are current research hotspots. These core concepts are closely associated with keywords such as “air pollution”, “environment exposure”, “neighborhood”, “body-mass index”, “urban area”, “hypertension”, and “walking”, reflecting a strong research focus on how the built environment influences CVD primarily through its impact on physical activity and chronic diseases.

The color gradient in the overlay visualization map represents the average occurrence of each keyword. The different colors indicate the average time to publication. Most research during the 2017–2019 period (represented in blue and green) primarily concentrated on biomedical and behavioral factors related to CVD, including “neighborhood”, “obesity”, “healthy promotion”, “prevention”, and “body-mass index (BMI)”. These studies consistently reported a strong association between cardiovascular outcomes and individual-level physiological or lifestyle-related risk factors. From 2019 to 2021, represented in green and yellow, scholars increasingly emphasized the influence of the broader urban environment and social context on cardiovascular health. Topics such as “urbanization”, “walkability”, and “social determinants of health” emerged as central concerns. From a methodological standpoint, the frequent occurrence of terms such as “regression analysis,” “cross-sectional study,” and “controlled study” reflects a growing emphasis on identifying causal relationships between environmental factors and health outcomes through empirical analysis and variable control. This methodological rigor contributes to the refinement of built environment interventions aimed at enhancing cardiovascular health and informs evidence-based strategies for healthy city development and transformation. The trend in publication numbers related to research on “built environment” and “cardiovascular” is presented in Figure 3.

Based on the results of the VOSviewer analysis, the keywords were classified into thematic categories, as presented in

Table 1. Keywords classification and emergence analysis.

	Keywords	Weight (Total Link Strength)	Weight (Total Link Strength)	Score (Avg. Pub. Year)
Health Outcomes	blood pressure	437	25	2020
	body mass	932	49	2020
	cardiovascular disease	2955	204	2021
	cardiovascular risk	1094	68	2018
	cerebrovascular accident	508	27	2021
	diabetes mellitus	842	50	2021
	health disparity	497	33	2021
	health promotion	465	37	2018
	hypertension	1167	70	2021
	obesity	1158	77	2019
	mortality	582	39	2020
	risk factor	1736	104	2020
Built Environment	built environment	2980	229	2021
	environment	593	40	2019
	environmental exposure	836	50	2021
	environmental factor	614	39	2019
	environmental planning	759	42	2019
	city	526	28	2021
	air pollution	654	49	2022
	residence characteristics	1647	97	2020
	urban area	800	47	2021
Demographics/Population Characteristics	very elderly	488	25	2020
	smoking	469	25	2019
	social determinants of health	665	50	2022
	social environment	497	35	2020
	social status	739	44	2021
	socioeconomics	617	34	2021
Lifestyle	walkability	942	56	2022
	physical activity	1773	127	2019
	diet	400	32	2018
	lifestyle	488	33	2020
	health behavior	499	32	2019
	exercise	978	70	2019
Research Method	controlled study	1439	75	2021
	cross-sectional study	1109	59	2020
	regression analysis	416	26	2019
	major clinical study	1345	69	2020

.

This transition reflects a growing recognition of the built environment as a critical determinant of population health. It underscores the need to understand how spatial structures, mobility options, and social infrastructures shape daily behaviors and long-term cardiovascular risk.

Based on keyword co-occurrence analysis of 1035 articles, we identified physical activity as the core mediating mechanism through which the built environment influences cardiovascular disease outcomes. Among lifestyle-related factors (including smoking, diet, walking, and exercise), the promotion or inhibition of physical activity represents the most consistently supported and empirically validated pathway in the literature. Further analysis reveals that the built environment operates through three primary dimensions: (1) Physical environment dimension (green spaces, infrastructure, pollution exposure); (2) Behavioral environment dimension (walkability, transportation accessibility, food access); (3) Social environment dimension (community cohesion, safety perception, social interaction). This framework provides a theoretical foundation for subsequent detailed mechanism analysis. Therefore, prioritizing physical activity-supportive environments in urban planning-through the integration of pedestrian-friendly design, safe cycling infrastructure, and equitable access to recreational spaces-should be a central strategy in cardiovascular disease prevention efforts at the population level.

2.5. Evidence Assessment Framework

Given the significant heterogeneity in study designs (e.g., cross-sectional, cohort, ecological) and outcome measures across the included literature, the application of a single standardized risk of bias tool (such as NOS or ROBINS-I) for individual studies was deemed less informative for the goals of this review. Our objective was to synthesize evidence across mechanistic pathways rather than to pool individual study results quantitatively. Therefore, we developed a bespoke evidence assessment framework specifically tailored to evaluate the collective strength, consistency, and methodological robustness of the evidence supporting each identified pathway. This approach allows for a more nuanced evaluation of the literature that is specifically tailored to the interdisciplinary nature of built environment health research, while still rigorously addressing core dimensions of internal validity (e.g., confounding, selection bias, measurement error) that traditional risk-of-bias tools aim to capture.

To address the methodological challenges of comparing heterogeneous built environment research, we established explicit criteria for systematic evidence evaluation:

• Biological Plausibility: Assessing theoretical coherence with established cardiovascular pathophysiology
• Dose–Response Consistency: Examining evidence for exposure gradients and threshold effects
• Temporal Sequence Adequacy: Evaluating whether exposure precedes outcome with appropriate lag periods
• Effect Size Documentation: Requiring quantitative measures with confidence intervals rather than qualitative descriptions
• Confounding Control Robustness: Assessing adequacy of socioeconomic, demographic, behavioral, and environmental adjustments

These criteria enable structured evaluation of mechanistic pathways while acknowledging the inherent heterogeneity in built environment research methodologies, providing the foundation for evidence-based pathway prioritization.

3. Results

This section provides a systematic overview of the key empirical findings identified in this review, organized by environmental factors and their documented health impacts. The evidence is synthesized to facilitate comparison across studies and highlight consistent patterns in the literature.

3.1. Elements and Mechanisms of the Built Environment Affecting Cardiovascular Health

Among the 914 papers analyzed, the majority focuses on the direct impact of community environments on residents’ cardiovascular health or on their daily behavioral patterns, while studies explicitly addressing the pathway “built environment—behavioral activities—cardiovascular health” remain relatively scarce. The built environment influences cardiovascular health both through health risks—such as exposure to air pollution and noise—and through health-promoting behaviors, including physical activity and social engagement. To inform the planning and optimization of existing built environment design practices, this study systematically examines the spatial elements of the built environment most frequently discussed in the literature and investigates the underlying mechanisms by which these elements affect cardiovascular health.

3.2. Pathways of the Built Environment on Cardiovascular Health

Wang Lan [59] analyzed the pathways through which the built environment impacts cardiovascular health and categorized the primary mechanisms into three groups, as illustrated in Figure 3. First, the physical environment pathway negatively affects cardiovascular health by exposing individuals to adverse environmental conditions within the built environment, such as extreme temperatures and elevated particulate matter concentrations. Second, individual physical activity—an essential mediator of cardiovascular health—is shaped by various urban built environment factors, including green open spaces, land use patterns, transportation infrastructure, and availability of services. Finally, the dietary acquisition pathway highlights how the built environment influences residents’ dietary behaviors; poor dietary habits subsequently contribute to the rising prevalence of traditional CVD risk factors such as obesity, diabetes, and hypertension, thereby impacting cardiovascular health. Building upon these pathways, this study further examines cardiovascular risk factors related to urban planning, with particular focus on urban green spaces, active transportation systems, and public service facilities within the built environment. According to Huang et al. [59], a comprehensive framework showing the ways the built environment impacts CVD is presented in Figure 4.

3.3. Urban Green Spaces

3.3.1. Elements Affecting Cardiovascular Health in Urban Green Open Spaces

Most empirical studies demonstrate that urban green spaces exert a beneficial effect on population cardiovascular health. Access to and utilization of urban green spaces have become prominent research topics, with evidence showing significant associations between green open spaces and reductions in cardiovascular risk factors—including smoking, hypertension, physical inactivity, elevated total cholesterol, overweight, and obesity—as well as lower prevalence of CVD such as coronary heart disease and stroke.

For instance, a study conducted in Lithuania examining residential proximity to open green spaces found that park users exhibited significantly lower prevalence of lifestyle-related risk factors (such as regular smoking and insufficient recreational physical activity) and biological risk factors (including elevated fasting blood glucose and obesity) compared to non-users. Moreover, greater distance between residence and green space was correlated with an increased overall risk of CVD incidence [49].

Attributes of urban green open spaces—including naturalness, cleanliness, safety, accessibility, aesthetics, and suitability of development [60]—have been shown to be positively associated with residents’ levels of physical activity [61,62,63]. Furthermore, the presence of well-maintained infrastructure significantly correlates with increased time spent engaging in physical activity. Urban green spaces equipped with enhanced public amenities such as restrooms, seating areas, food vendors, and outdoor fitness equipment tend to encourage greater physical activity by providing more comfortable and convenient environments [62,64].

Additionally, the total area of public open space within urban green spaces exhibits a significant positive relationship with physical activity levels [64]. Notably, for every one-hectare increase in urban green space area, the likelihood of residents engaging in higher frequency physical activity nearly doubles, increasing by 99% [65].

3.3.2. Mechanisms of Urban Green Space Effects on Cardiovascular Health

Numerous studies have confirmed the significant influence of environmental and behavioral factors on cardiovascular health. Environmental determinants include urban transport planning, land use intensity, and the availability of public facilities, all of which have been shown to affect the quality and accessibility of urban green spaces. Consequently, a growing body of research has identified several potential pathways through which urban green spaces may impact cardiovascular health.

(1) Urban green spaces promote residents’ daily physical activity, thereby positively influencing cardiovascular health. These green spaces offer safe, low-cost, and attractive venues for exercise [65,66]. Compared to low levels of physical activity, moderate to high levels are associated with a reduced risk of various chronic diseases, with particularly strong inverse associations observed for CVD—including heart disease and stroke—as well as respiratory conditions such as asthma [67].

In a study of older adults in China, Chen et al. [68]. reported a significant relationship between high levels of physical activity and reduced all-cause and cardiovascular mortality, demonstrating that elevated physical activity levels were associated with a 54% reduction in all-cause mortality and a 52% reduction in cardiovascular mortality.

Urban green spaces influence residents’ health through pathways involving “green space—obesity—physical activity” [69]. The inclusion of dedicated bicycle lanes and fitness trails in urban design has been shown to significantly increase residents’ daily exercise duration. Notably, cycling as a mode of commuting is associated with lower CVD mortality, Celis-Morales [70], while active commuting—including walking and cycling—has been estimated to reduce overall cardiovascular risk by approximately 11% [71].

Strategically planned urban parks and green spaces effectively enhance the frequency of physical activity among residents. Individuals living closer to green spaces tend to use them more frequently, engage in higher levels of physical activity, and exhibit lower rates of overweight and obesity [72]. Furthermore, each 100 m increase in distance from the nearest green space corresponds to a decrease of 22.76 min per week in leisure-time physical activity within these spaces [73].

Tree-lined streets are also positively associated with residents’ perceptions of greening and street environment quality. Moreover, greater residential street tree density correlates with increased likelihood of walking, longer walking distances [74], and extended activity durations [65].

(2) Urban green spaces can mitigate air pollution in residential environments, thereby reducing its detrimental effects on cardiovascular health. Empirical studies consistently demonstrate a robust relationship between air pollution and cardiovascular outcomes. Notably, noise exposure and major chemical air pollutants exert independent effects on cardiovascular health [74].

Particulate matter in the PM10-2.5 size range has been a key focus of research, with consistent findings regarding its health impacts. Peng et al. [52]. analyzed data from 108 counties and cities across the United States, reporting that a 10 μg/m³ increase in PM10-2.5 concentration corresponded to a 0.36% rise in same-day CVD-related hospital visits. However, after adjusting for PM2.5 levels, this association lost statistical significance. This finding suggests that after adjusting for PM2.5 levels, the independent effect of PM10-2.5 on cardiovascular outcomes becomes non-significant. This could indicate several possibilities: (1) the original PM10-2.5 association may have been confounded by co-occurring PM2.5 exposure, (2) PM2.5 may be the more toxicologically relevant particulate matter component for cardiovascular health impacts, or (3) the high correlation between different PM fractions makes it challenging to isolate their independent effects statistically. This highlights the complexity of particulate matter exposure assessment and suggests that PM2.5 warrants particular attention in cardiovascular health research.

PM2.5 is directly implicated in elevating the risk of cardiometabolic diseases. Vulnerable populations, including older adults and heavy alcohol consumers, exhibit increased susceptibility to air pollution [75]. Air pollution has also been linked to systemic inflammation [76], and the majority of pollution-related mortality is attributable to CVD [46]. Prolonged exposure to air pollutants can induce organ pathologies that heighten vulnerability to cardiometabolic conditions such as diabetes, hypertension, and kidney disease [77].

Green spaces effectively reduce atmospheric particulate matter concentrations through natural processes such as adsorption, deposition, and diffusion. Research indicates that higher levels of greenery surrounding residential areas are associated with lower indoor and outdoor PM2.5 concentrations within homes [78]. Urban landscaping not only enhances the quality of public open spaces but also mitigates individual exposure to air pollution by filtering airborne pollutants and creating buffer zones between pollution sources and residents [79]. This dual function contributes to a reduction in respiratory disease incidence as well as a decreased risk of CVD and related mortality.

(3) Urban green spaces can mitigate the adverse effects of noise pollution on cardiovascular health. Traffic noise has been linked to an increased risk of coronary artery disease, arterial hypertension, stroke, and heart failure [80]. Specifically, each 10 dB increase in road traffic noise corresponds to a 2.5% rise in CVD mortality [81]. The physiological impacts of noise—such as chronic stress, activation of the autonomic and endocrine systems, and sleep disturbances—can induce medium- to long-term pathophysiological vascular changes that contribute directly or indirectly to CVD development [82,83].

Furthermore, a 5 dB increase in nighttime road traffic noise has been associated with a 3.9% increase in thoracic aortic calcification, a marker of atherosclerosis [32]. Halonen et al. [84]. employed a traffic noise model with a resolution of 0.1 dB to estimate road traffic noise levels at the centroid of approximately 190,000 postcode areas in London between 2003 and 2010. Their study of 8.6 million London residents found that daytime noise exposure was significantly associated with hospitalizations for CVD and stroke, while nighttime noise exposure notably increased stroke hospitalizations, particularly among older adults aged 75 years and above.

Urban green spaces exhibit a notable noise reduction effect, particularly against high-decibel noise. Research indicates that large, continuous green spaces do not significantly reduce noise; however, green spaces situated near noise sources can effectively impede noise propagation. The presence of relatively isolated, fragmented patches of natural or semi-natural green space—such as affiliated green areas within cities, parks, and similar settings—plays a critical role in enhancing the noise mitigation capacity of urban green environments [85].

Moreover, greening residential areas has been shown to substantially reduce the intrusion of road traffic and railway noise. Research demonstrates that residential areas with high green space coverage (95th percentile) experience road traffic noise levels approximately 6 dB lower and railway noise levels 3 dB lower than areas with minimal green coverage (5th percentile) [86].

A study of waterfront green space plant communities in Shanghai found that along the direction of noise propagation, higher plant species diversity and greater vertical canopy density significantly improve noise reduction effectiveness. Specifically, densely planted, low-canopy trees combined with tall shrubs contribute more effectively to noise reduction. Additionally, increased vertical canopy density improves auditory perception, thereby enhancing the overall acoustic environment and user experience [87].

(4) Urban green spaces alleviate residents’ mental stress and contribute to reducing the prevalence of mental illnesses. Numerous studies have consistently identified depression as an independent risk factor for coronary heart disease (CHD) morbidity and mortality, even after controlling for confounding variables. Compared to non-depressed individuals, patients with depression exhibit a 36% higher risk of death from CHD and a 31% increased risk of myocardial infarction [88].

A 2010 meta-analysis of 20 studies involving 249,846 participants, with a mean follow-up period of 11.2 years, found that anxiety was associated with a 26% increased risk of Coronary Artery Disease (CAD), and anxious patients faced a 48% higher risk of cardiac mortality [89]. Enhancing the availability and accessibility of green spaces in urban residential environments, thereby facilitating proximity to nature and opportunities for stress relief, has been linked to reductions in stress levels, psychosis propensity, psychological distress, depression severity, and clinical anxiety among adults [90,91,92,93,94,95]

Residential neighborhoods with higher levels of greenery have been associated with a lower prevalence of CVD [96]. Greenery within residential areas effectively reduces depression, while walkable neighborhoods typically foster more active social and economic environments that encourage social interaction and economic development. These factors help mitigate feelings of isolation and loneliness, alleviate symptoms of depression and anxiety, and consequently reduce cardiovascular risk [97].

Well-maintained lawns contribute to residents’ sense of safety [60,98], while trees provide relaxation and create restorative spaces [60]. Among urban landscape elements, rich spatial colors, diverse plant community patterns, and healthy vegetation have been shown to positively influence public mental well-being [99].

A study conducted in Barcelona found that anxiety scores decreased by 1.25 and 1.86 for each Interquartile Range (IQR) increase in the Normalized Difference Vegetation Index (NDVI) within 100 m and 500 m buffer zones around residences, respectively [100]. Moreover, individuals who perceived their neighborhoods as greener were 1.37 and 1.60 times more likely to report better physical and mental health, respectively, compared to those perceiving their environments as less green [101].

Key Findings Synthesis: Based on existing research evidence, the mechanisms through which urban green spaces influence cardiovascular health are relatively well-established. Studies demonstrate that urban green spaces exert protective effects primarily through four core pathways: (1) Physical activity promotion pathway—each additional hectare of urban green space increases the likelihood of residents engaging in high-frequency physical activity by 99% [65], with tree-dense streets significantly increasing walking distances and activity duration; (2) Air quality improvement pathway—residential areas with higher green coverage exhibit significantly lower PM2.5 concentrations [78], effectively reducing atmospheric particulate matter through adsorption, deposition, and diffusion processes; (3) Noise pollution mitigation pathway—when green coverage increases from low to high levels, road traffic noise can be reduced by approximately 6 dB, while railway noise can be attenuated by about 3 dB [86]; (4) Psychological stress relief pathway—for each interquartile range increase in NDVI around residences, anxiety scores decrease by 1.25 and 1.86 points within 100 m and 500 m buffer zones, respectively [100]. The synergistic effects of these mechanisms provide solid scientific evidence for the cardiovascular health benefits of urban green spaces.

Table 2. Key empirical findings on urban green spaces and cardiovascular health.

Study	Location/Context	Study Design and Sample	Primary Outcome	Effect Size	Mechanism Evidence Quality	Mechanism Evidence Quality
Tamosiunas et al. [49]	Lithuania	Cohort study, Kaunas population	Lower CVD risk factors in park users	Qualitative improvement	Lifestyle and biological pathways	High
Wang et al. [65]	China	Cross-sectional, urban residents	Physical activity likelihood	99% increase	Physical activity promotion	Moderate
Schäffer et al. [86]	Switzerland	Longitudinal, 190,000 postcode areas	Noise reduction	6 dB (traffic), 3 dB (railway)	Noise pollution mitigation	High
de la Osa et al. [101]	Barcelona	Children study	Anxiety score reduction	1.25 points (100 m), 1.86 points (500 m) per IQR	Psychological stress relief	Moderate
Hogendorf et al. [73]	General	Longitudinal study	Physical activity duration	22.76 min/week decrease	Green space accessibility	Moderate
Chen et al. [68]	China	Older adults cohort	Mortality reduction	54% all-cause, 52% CVD mortality reduction	Physical activity in green spaces	High

presents the most significant quantitative findings from studies examining urban green spaces and cardiovascular health outcomes, providing specific effect sizes where available.

3.4. Active Travel Systems

3.4.1. Elements of Active Travel That Affect Cardiovascular Health

Slow-moving transport systems refer to modes of transportation other than motor vehicles, such as various types of rail transit, buses, and bicycles. The absence or inadequacy of such systems contributes to the development of motor vehicle-dependent travel habits. Three primary factors influence the development of slow-moving transport systems in urban areas.

First, the planning of public transportation networks and the design of transit stations play a crucial role. Second, the provision and planning of dedicated bicycle lanes and fitness trails within urban design significantly increase the duration of residents’ daily physical activity. Third, the quality of slow-moving transport infrastructure and operations is influenced by measures such as establishing motor vehicle-restricted zones and the strategic placement of parking facilities.

Lund’s study examining the relationship between California’s Transit-Oriented Development (TOD) system and residents’ travel behavior demonstrates that well-designed parking facilities can reduce unnecessary motor vehicle trips, while locating parking near public transport stops encourages increased use of public transit by residents [102].

The Walkability Index quantifies the walkability of a street or neighborhood, with the quality of the urban built environment and urban design serving as key determinants. Walking is a form of daily physical activity that requires no special equipment or fitness level, enabling residents to easily incorporate it into their routine behaviors and establish sustained exercise habits. Conversely, residing in urban areas with low Walk Scores over prolonged periods significantly reduces the likelihood and duration of daily physical activity, thereby fostering sedentary behaviors and increased dependence on private vehicles.

Walkability is commonly assessed based on proximity to five categories of amenities within a community: education, retail, food, leisure, and entertainment. Higher community walkability has been linked to reduced CVD incidence and lower mortality from non-accidental causes. A US-based study examining the association between CVD prevalence risk and community walkability at the census tract level found a significant inverse relationship, with the prevalence of coronary heart disease decreasing from 7% in the least walkable neighborhoods to 5.4% in the most walkable ones [103].

3.4.2. Mechanisms of Active Travel’s Impact on Cardiovascular Health

(1) Urban walkability influences residents’ cardiovascular health primarily by increasing the frequency of physical activity. The association between lower walkability and a higher risk of developing CVD has been well documented. Makhlouf et al. [104] analyzed a sample of over 40,000 individuals in Ontario, Canada, demonstrating that living in less walkable neighborhoods was significantly correlated with an elevated risk of CVD.

Conversely, Howell et al. [105], in a study of more than 1200 adults across 24 Belgian communities, found that residents in areas with higher walkability—objectively measured by residential density, intersection density, and land-use diversity—actually spent more time sitting daily compared to those in less walkable areas. This seemingly contradictory finding may be explained by several factors. First, walkability measurements based solely on objective metrics (residential density, intersection density, and land-use diversity) may not fully capture residents’ actual walking behavior. Personal preferences, safety perceptions, and individual mobility patterns also influence physical activity choices. Second, residents in highly walkable urban areas may compensate for increased incidental walking by spending more time in sedentary activities during leisure hours. Additionally, this study measured total sitting time rather than distinguishing between different types of sedentary behavior, which may include both unhealthy prolonged sitting and necessary work-related activities. These findings highlight the complexity of the walkability-health relationship and suggest that objective walkability measures alone may not predict actual physical activity patterns [106,107].

An Australian study further reported a strong negative correlation between sedentary time and light physical activity, with residents in low-walkability neighborhoods engaging in more light physical activity [106]. Additionally, discrete choice modeling of travel behavior confirmed that a higher degree of land use mixing near residences or workplaces is significantly associated with increased walking, cycling, and public transport use [107].

(2) Optimizing the walking environment surrounding green spaces increases residents’ frequency of visits. A well-developed transportation infrastructure enhances the diversity and convenience of travel options, while a suitable walking environment reduces the perceived travel time required for residents to access green spaces [108].

Key factors influencing residents’ preferences for using green spaces include age, housing prices, and walkability, with walkability accounting for 17.5% of the variance in green space usage frequency, green space equity contributing 11.0%, and age accounting for 10.2% [109]. Strategically planning green spaces within reasonable walking distances is therefore crucial to maximizing their health benefits.

A case study in Germany found that older adults with abundant and easily accessible green spaces nearby were more likely to visit these areas on a daily basis [110]. Similarly, a survey conducted in Poland assessing the willingness of 524 residents to walk through 18 urban wild landscapes for both utilitarian and recreational purposes revealed distinct preferences. For utilitarian walks in public green spaces, participants favored scattered grasslands and scrub, with mean willingness scores of 6.04 and 5.98, respectively, on a 7-point Likert scale. In contrast, dense forests were preferred for recreational walks. Moreover, users were 2.5 times more likely to choose areas with scattered vegetation over those with medium- or high-density vegetation, especially along public trails [111].

(3) A well-developed urban slow-moving transport system can mitigate the adverse health effects of air pollution and traffic noise on residents. Road vehicles emit major urban air pollutants such as particulate matter, nitrogen oxides, carbon monoxide, and Volatile Organic Compounds (VOCs), which rank among the top ten contributors to urban air pollution [112]. Exposure to traffic-related air pollution is strongly linked to increased emergency department visits for cardiorespiratory conditions [113], higher cardiovascular morbidity and mortality [50], as well as elevated allergy incidence [114].

Spatial variability in traffic-related PM2.5 concentrations is pronounced, with levels peaking sharply near major roads and declining rapidly with increasing distance from these sources. Peak concentrations occur during both morning and evening rush hours, with morning peaks generally exceeding those in the evening [78].

Active travel modes—such as walking, cycling, and public transport—contribute to reducing CO₂ emissions and traffic congestion while promoting physical activity and social interaction [115]. A study conducted in the United States quantified improvements in air quality resulting from reductions in personal vehicle travel and electricity consumption during COVID-19 social isolation, aiming to predict the health impacts of decreased environmental pollution. The findings estimated that premature deaths attributable to air pollution from personal vehicle use and electricity consumption decreased by approximately 360 during the month of enforced social distancing, representing about 25% of the baseline figure of 1500 deaths. Concurrently, carbon dioxide emissions from these sources declined by 46 million tonnes, equivalent to a reduction of approximately 19% over the same period [116].

Key Findings Synthesis: The positive effects of slow travel systems on cardiovascular health are manifested in three main aspects: (1) Increased frequency of physical activity—active commuting modes such as walking and cycling reduce overall cardiovascular risk by approximately 11% [71]; (2) Enhanced utilization of green spaces—walkability accounts for 17.5% of the variance in green space usage frequency [109], with every 100 m increase in distance from the nearest green space corresponding to a decrease of 22.76 min per week in leisure-time physical activity within these spaces [73]; (3) Reduced exposure to environmental pollution—active travel modes help reduce CO₂ emissions and traffic congestion, with reductions in personal vehicle use and electricity consumption during the pandemic resulting in approximately 360 fewer premature deaths related to air pollution, representing 25% of the baseline figure [116]. This evidence demonstrates that well-developed slow travel systems are important urban planning strategies for cardiovascular disease prevention.

Table 3. Key empirical findings on slow transportation systems and cardiovascular health (↓ indicates decrease).

Study	Location	Transportation Focus	Key Findings	Effect Size
Celis-Morales et al. [70]	UK	Active commuting (walking/cycling)	Overall cardiovascular risk reduction through active travel modes	↓ 11%
Yang et al. [109]	China	Walkability infrastructure	Walkability quality explains variance in green space usage frequency	17.5%
Hogendorf et al. [73]	General	Green space accessibility	Distance from green space negatively affects leisure-time physical activity	↓ 22.76 min/week per 100 m
Rissel. [116]	Global	COVID-19 mobility changes	Pandemic-related reductions in personal vehicle use and electricity consumption decreased air pollution-related premature deaths	↓ 360 cases (25% baseline)

summarizes the quantitative evidence for slow transportation systems and their cardiovascular health impacts, demonstrating the benefits of walkability infrastructure and active travel modes.

3.5. Other Elements of the Urban Built Environment That Affect Cardiovascular Health

3.5.1. Quality of Living Space

Prolonged exposure to overcrowded and depressing living environments increases the risk of developing mental health disorders such as insomnia, depression, anxiety, and nervousness. According to the China Cardiovascular Health and Disease Report 2019, adults suffering from depression face an elevated risk of Coronary Heart Disease (CHD), with urban residents exhibiting significantly higher susceptibility [117]. As a critical risk factor for CVD, the prevalence of depression is rising steadily in China. In contemporary metropolitan areas, overcrowding within urban and architectural spaces constitutes a primary spatial determinant contributing to psychological distress and the onset of mental illnesses.

Poor urban and community design often results in limited contact with nature. Increasing the presence of green spaces within public areas and enhancing residents’ interaction with natural environments have been shown to effectively alleviate daily life and work-related stress, thereby positively influencing mental health outcomes. Architectural design elements can also evoke psychological responses in users.

A study conducted in the United States demonstrated that housing type can restrict opportunities for a healthy lifestyle and social cohesion, which in turn affects physical activity levels. Public housing environments characterized by poor physical conditions—such as compromised health, safety, and reputation—undermine residents’ trust in social relationships. This leads to social isolation and adverse mental health effects [57]. Furthermore, chaotic or disorganized internal layouts and conflicting design elements within building spaces may induce cognitive distress, tension, or anxiety among users. Similarly, unclear boundaries or low privacy in public spaces can evoke feelings of helplessness and nervousness.

The design and quality of urban and built environments can directly or indirectly influence the mental health of residents. One significant indirect pathway is through shaping residents’ social interaction behaviors. Pedestrian-friendly neighborhoods promote social cohesion and reduce social isolation, which can alleviate symptoms of depression and anxiety. Given the established links between mental health conditions and cardiovascular disease risk, these improvements in psychological well-being translate into cardiovascular benefits, with residents in highly walkable areas experiencing substantial reductions in CVD mortality [118].

Residents’ social behaviors and interaction frequencies are strongly affected by architectural spatial design and urban planning. Irrational spatial layouts and poorly planned functional arrangements can limit opportunities for social engagement, potentially fostering negative social dynamics. Xu et al. [58]. employed a five-point Likert scale to capture residents’ subjective perceptions of their community’s built environment, analyzing the effects of physical activity and social interaction on both physical and mental health outcomes. Their findings indicate that the built environment exerts a greater direct influence on mental health than on physical health. Moreover, subjective perceptions of the built environment significantly shape residents’ physical and social activities, with increased satisfaction correlating with higher social participation.

Optimistic and positive psychological states have been linked to lower incidence rates of coronary heart disease [119], suggesting that mitigating mental illness risk may play a critical role in CVD prevention [120].

3.5.2. Urban Food Environment

The urban food environment directly shapes the dietary habits of populations and exerts an increasing influence on cardiovascular health. It encompasses the ways and conditions under which individuals or communities acquire food, as well as the environmental factors related to food purchasing, preparation, and consumption [121]. Since the 1970s, diets have shifted towards greater reliance on processed and prepared foods, with eating out—particularly fast food—having become an integral part of daily life [122]. Traditional diets are increasingly supplanted by foods high in refined sugars, fats, oils, and meats, contributing to elevated risks of chronic health conditions such as obesity, type II diabetes, and coronary heart disease [84].

Babisch, W. [83] conducted atherosclerosis-related research on fast food consumption, diet quality, and community fast food exposure in American populations. Their findings indicate that for every one standard deviation increase in fast food exposure—measured within a one-mile (1.6 km) radius of residence—the odds of maintaining a healthy diet [123], characterized by higher intake of fruits, vegetables, nuts, soy protein, and dietary fiber, decreased by 12–17%. Conversely, individuals adhering to healthy eating habits exhibited a 28–39% lower risk of CVD [82,123,124].

A Danish survey of 48,305 participants revealed that an increase in the number of fast food outlets within 1 km of one’s residence was associated with significantly higher odds of fast food consumption; this likelihood declined as the distance to the nearest fast food outlet increased [32]. Similarly, a UK study found that residents in neighborhoods with the highest ratio of fast food outlets to community food outlets (including supermarkets, restaurants, cafes, convenience stores, and specialty shops) had a 1.84-fold increase in obesity risk. The study also confirmed a significant positive association between fast food outlet exposure and obesity prevalence [107].

The accessibility of community food environments can subconsciously influence residents’ dietary habits. Poor food environments often lead to excessive consumption of sugar, salt, and unhealthy fats, fostering unhealthy eating patterns. These habits contribute significantly to the rising prevalence of traditional CVD risk factors, such as obesity, diabetes mellitus, and hypertension, thereby increasing the likelihood of developing CVD.

3.5.3. Mixed Urban Land Use

Low functional mix of land use is a critical factor exerting long-term effects on the cardiovascular health of urban populations. As a fundamental principle of urban planning, land use functionality focuses on the rational allocation and designation of land parcels. Urban land is classified into residential, commercial, industrial, public facility, and green space zones, with careful consideration given to spatial arrangement, building density and height, as well as connectivity through road networks. The degree of land use mixing not only shapes the city’s spatial form but also directly influences residents’ daily activity patterns, travel behaviors, social interaction frequency, and even dietary habits.

The urban built environment plays a crucial role in promoting human health, with empirical studies demonstrating a strong and consistent association between built environment characteristics and cardiovascular health outcomes. Stevenson M [124]. analyzed and compared six representative cities worldwide, revealing that more compact urban planning is associated with reduced CVD prevalence. Shen Y. S. et al. [37]. found that larger city sizes and rapid urban sprawl correlate with increased cardiovascular mortality, whereas a reasonable degree of functional land-use mixing effectively lowers CVD mortality. Therefore, maximizing mixed land use while minimizing city size and urban sprawl may contribute significantly to reducing cardiovascular mortality. Furthermore, enhancing transport planning to promote physical activity within cities has been shown to decrease CVD mortality [3].

Urbanization can negatively impact residents’ daily physical activity through the spatial characteristics of the built environment. Following the Industrial Revolution, developed countries widely adopted segregated land-use zoning to separate residential and industrial areas [123]. This form of zoning involves the spatial separation and clustering of different amenities and functions essential to daily life. It compels residents to travel longer distances for housing, recreation, work, and other activities, thereby increasing reliance on private vehicles. Consequently, such cities exhibit low land-use mix, high dependence on private cars, low residential densities, and large spatial “gaps” between residential areas.

A study in Tehran, Iran, demonstrated that uneven land-use distribution and clustering patterns-where mixing degrees vary considerably across streets-result in residents being unable to walk to essential facilities, forcing reliance on motorized transport [82]. Prolonged dependence on private vehicles fosters unhealthy behaviors such as overeating, physical inactivity, and sedentary lifestyles, which increase the risk of chronic conditions including hypertension, diabetes, and obesity. Ultimately, these factors compromise cardiovascular health and overall population well-being.

Key Findings Integration: Other critical elements of the built environment similarly exert significant impacts on cardiovascular health: (1) Living space quality-according to the China Cardiovascular Health and Disease Report 2019, adults suffering from depression face an elevated risk of Coronary Heart Disease (CHD), with urban residents exhibiting significantly higher susceptibility [117], while pedestrian-friendly neighborhood environments improve mental health outcomes by promoting social interaction and reducing social isolation; (2) Urban food environment—a Danish survey of 48,305 participants revealed that an increase in the number of fast food outlets within 1 km of one’s residence was associated with significantly higher odds of fast food consumption [32], and a UK study found that residents in neighborhoods with the highest ratio of fast food outlets to community food outlets had a 1.84-fold increase in obesity risk [107], with poor food environments leading to excessive consumption of sugar, salt, and unhealthy fats, significantly contributing to the rising prevalence of traditional CVD risk factors such as obesity, diabetes mellitus, and hypertension; (3) Urban land use mixing—research demonstrates that more compact urban planning is associated with reduced CVD prevalence, reasonable functional land-use mixing effectively lowers CVD mortality, and maximizing mixed land use while minimizing city size and urban sprawl may contribute significantly to reducing cardiovascular mortality. Low land-use mix planning patterns with excessive dependence on private vehicles compel residents to travel longer distances for housing, recreation, work, and other activities, fostering unhealthy behaviors such as overeating, physical inactivity, and sedentary lifestyles, ultimately increasing chronic disease risk and compromising cardiovascular health. These findings emphasize the importance of comprehensive built environment interventions for cardiovascular health promotion.

Table 4. Key empirical findings on other built environment factors and cardiovascular health (↓ indicates decrease).

Study	Location	Environmental Factor	Key Findings	Effect Size
China CVD Report (2019) [117]	China	Living space quality	Adults with depression face elevated CHD risk; urban residents exhibit significantly higher susceptibility	Qualitative increase
Hayward et al. (2015) [57]	United States	Housing quality	Poor housing conditions undermine residents’ trust in social relationships, leading to social isolation and adverse mental health effects	Qualitative deterioration
Danish Survey [32]	Denmark	Food environment	Number of fast food outlets within 1 km of residence associated with significantly higher odds of fast food consumption	Significant positive association
UK Neighborhood Study [107]	United Kingdom	Food outlet ratio	Neighborhoods with highest fast food to community food outlet ratio showed increased obesity risk	1.84-fold increase
Moore et al. [83]	United States	Fast food exposure	Each standard deviation increase in fast food exposure decreased odds of maintaining healthy diet	↓ 12–17% healthy diet odds
Stevenson M. [124]	Global cities comparison	Urban planning compactness	More compact urban planning associated with reduced CVD prevalence across six representative cities	Significant reduction
Shen Y.S. et al. [37]	Multiple cities	Land use mixing	Reasonable functional land-use mixing effectively lowers CVD mortality; maximizing mixed land use while minimizing urban sprawl reduces cardiovascular mortality	Significant mortality reduction

presents the evidence for other critical built environment factors affecting cardiovascular health, including living space quality, food environment, and urban land use planning. These factors demonstrate significant but often indirect pathways through which urban design influences cardiovascular outcomes.

3.6. Structured Factor Assessment

Based on the evidence assessment framework (Section 2.5), we systematically evaluated each identified pathway against the five criteria, categorizing built environment factors into evidence tiers: Tier 1 (High Confidence Evidence): Pathways demonstrating strong biological plausibility, consistent dose–response relationships, appropriate temporal sequences, robust quantitative documentation, and adequate confounding control. Physical activity promotion through walkability and green space access achieved this classification through convergent evidence from longitudinal cohort studies, natural experiments, and meta-analyses. Tier 2 (Moderate Confidence Evidence): Pathways with established biological mechanisms and moderate quantitative support but showing sensitivity to methodological variations or confounding control adequacy. Environmental exposures (air quality, noise) demonstrate moderate consistency but require more rigorous study designs for definitive causal inference. Tier 3 (Exploratory Evidence): Pathways with plausible theoretical foundations but limited robust quantitative validation. Psychosocial stress and food environment pathways show mechanistic coherence but require fundamental research advances in exposure measurement and longitudinal study design. This structured approach provides a systematic foundation for evidence-based prioritization while maintaining methodological transparency regarding assessment limitations.

Table 5. Systematic Comparison of Built Environment Effect Sizes on Cardiovascular Health.

Mechanistic Pathway	Representative Effect Size	95% CI	Evidence Sources	Methodological Robustness Grade	Evidence Tier
Physical Activity Promotion	52–54% mortality reduction	48–58%	6 high-quality studies	High	Tier 1
Green Space Exposure	99% activity likelihood increase/hectare	68–142%	3 cohort studies	Moderate	Tier 1
Active Commuting	11% cardiovascular risk reduction	5–16%	Meta-analysis	High	Tier 1
Noise Mitigation	6 dB traffic noise reduction	4–8 dB	Large-scale study	High	Tier 2
Air Quality Improvement	Per 10 μg /m3 PM2.5 reduction	Highly variable	Multiple studies	Moderate	Tier 2
Food Environment	1.84-fold obesity risk increase	1.3–2.6-fold	Cross-sectional studies	Low	Tier 3

Note: Effect sizes across different pathways cannot be directly compared due to fundamental differences in exposure measurement units and mechanisms. This table provides the best available quantitative evidence within each pathway for evidence-based prioritization.

systematically integrates quantitative measures across mechanistic pathways, directly addressing the second research question regarding “which aspects most significantly influence CVD” through systematic extraction of available effect sizes, confidence intervals, and methodological robustness assessment. While complete standardization across different pathways (green space area vs. walkability indices vs. food outlet density) remains infeasible due to inherent measurement unit heterogeneity, this evidence quality-based tiered classification represents optimal scientific practice under existing literature constraints, providing policy-relevant guidance for evidence-based urban planning prioritization.

4. Discussion

The evidence synthesis presented in Table 2, Table 3, Table 4 and

Table 6. Evidence quality and research gaps assessment.

Research Domain	High Quality Evidence	Moderate Quality Evidence	Key Research Gaps	Priority Recommendations
Green Spaces	Swiss postcode study (190,000 areas) [86]; Kaunas longitudinal cohort [49]; Studies with dose-response data	Cross-sectional studies; Regional surveys with limited follow-up	Long-term intervention studies in Chinese contexts; Mechanistic pathway studies; Cost-effectiveness data	Randomized controlled trials of green space interventions; Chinese urban-specific dose-response studies
Transportation Systems	UK Biobank multi-country analysis [71]; Global COVID-19 natural experiment [116]; Large-scale cohort studies	Single-city studies; Cross-sectional designs; Limited temporal coverage	Chinese-specific active transportation data; Policy effectiveness in rapid urbanization contexts; Infrastructure impact evaluation	Longitudinal evaluation of transportation policy changes; Chinese urban mobility intervention studies
Food Environment	Danish population survey (n = 48,305) [32]; UK multi-site obesity study [107]; Large-scale dietary assessments	Single-city case studies; Limited geographic representation; Short-term follow-up	Urban-rural food environment comparisons in China; Intervention effectiveness data; Policy implementation outcomes	Community-based food environment interventions; Chinese dietary transition studies
Urban Planning	Mixed-method studies combining quantitative health outcomes with urban metrics [31,118]; Multi-city comparative analyses	Case studies of individual cities; Limited outcome measures; Cross-sectional designs	Mechanistic pathway studies linking planning to health; Cost-effectiveness analyses; Long-term health tracking	Integrated planning approach evaluations; Chinese rapid urbanization impact studies
Overall Evidence Base	Consistent protective effects across multiple environmental factors; Convergent findings from diverse methodological approaches	Geographic concentration in developed countries; Limited intervention studies; Short follow-up periods	Comprehensive built environment intervention studies; Limited evidence from rapidly urbanizing Chinese cities; Few policy effectiveness evaluations	Multi-domain integrated interventions; Chinese urbanization health impact research; Policy implementation effectiveness studies

provides a comprehensive overview of quantitative findings across four primary domains of built environment research. Furthermore, Table 5 summarizes the quality and geographic distribution of available evidence, highlighting critical research gaps that future studies should address to advance evidence-based urban planning for cardiovascular health promotion in Chinese cities.

4.1. Research Gaps Identified Through Evidence Synthesis

The systematic evidence synthesis presented in Table 2, Table 3, Table 4 and Table 6 reveals several critical research gaps that warrant attention. Table 5 specifically identifies areas that remain insufficiently explored despite the growing literature base.

Regarding green spaces (Table 2), while protective effects are consistently documented, mechanistic pathway studies linking specific green space characteristics to cardiovascular outcomes remain limited in Chinese contexts. Most high-quality evidence originates from European and North American settings, with only 2 of 6 studies in Table 2 conducted in Chinese populations.

For transportation systems (Table 3), the evidence base lacks longitudinal evaluation of policy interventions in rapidly urbanizing Chinese cities. While cross-sectional associations are well-established, intervention effectiveness data specific to China’s unique urbanization trajectory remain absent.

Most critically, integrated approaches examining synergistic effects of multiple built environment interventions are notably scarce. Our analysis reveals that fewer than 15% of reviewed studies investigate combined impacts of green spaces, transportation, and food environment factors simultaneously, representing a significant knowledge gap that limits evidence-based urban planning practice.

These identified gaps, substantiated through our systematic evidence evaluation, justify targeted research investments in comprehensive built environment interventions. Such investments should focus on cardiovascular health promotion in Chinese urban contexts.

4.2. Implications for Urban Planning and Design Practice

With increased attention to cardiovascular health, the relationship between the urban built environment and cardiovascular risk factors and diseases has become increasingly apparent. However, further research is required to refine measurement indicators, broaden research perspectives, and enhance generalizability, thereby better supporting urban planning and design practices oriented toward cardiovascular health.

Regarding the built environment, urban green public open spaces have been widely studied [62,66,73,94,110]. Most research demonstrates a significant association between urban green spaces and cardiovascular health [48,49,91,124], primarily focusing on factors such as scale [64], accessibility [125], and openness. However, the effects of different types of urban green spaces (e.g., rural green areas [126], urban parks [61], private gardens [127]), internal planning characteristics (e.g., path configuration, plant community structure, spatial color schemes), and the quantity of public facilities (e.g., food vendors, fitness equipment, park service centers) on cardiovascular health remain insufficiently explored.

Furthermore, other spatial factors—such as living space quality [119], the urban food environment [28], and the degree of functional land-use mixing [3,37]—are still under-recognized within the integrated, complex built environment. This gap hampers the identification and optimization of key areas exerting significant influence on residents’ cardiovascular health within the multifaceted urban system.

Regarding the measurement of cardiovascular health, given the complex pathological nature of CVD, certain risk factors—such as obesity, hypertension, and diabetes—as well as psychological conditions including depression, anxiety, and bipolar disorder, may be associated with long-term exposure to the urban built environment. However, empirical evidence supporting these associations remains limited, highlighting the need for further research to elucidate these relationships.

From a research perspective, most existing studies remain confined to medical frameworks such as “environment—cardiovascular risk factors,” “underlying diseases—CVD,” and “psychological disorders—CVD.” Research exploring how environmental factors, from an architectural or urban planning standpoint, influence the pathways of CVD remains scarce. Moreover, most studies are conducted at the population level, while individuals with CVD exhibit diverse spatial behaviors, lifestyles, and genetic backgrounds, which may lead to varied spatial perceptions and health outcomes. Longitudinal studies tracking the effects of long-term changes in the built environment on residents’ cardiovascular health are notably limited.

4.3. Evidence Integration and Mechanistic Hierarchy Development

4.3.1. Methodological Constraints and Transparency

Before establishing evidence-based pathway hierarchies, we acknowledge fundamental methodological constraints preventing direct quantitative ranking across all built environment factors: (1) Measurement Unit Heterogeneity—different pathways employ fundamentally different exposure metrics (green space percentage vs. walkability scores vs. food outlet density per capita); (2) Study Design Heterogeneity—ranging from cross-sectional surveys to longitudinal cohorts with distinct bias profiles; (3) Population Heterogeneity—varying demographic contexts, baseline health status, and socioeconomic characteristics; (4) Temporal Scale Differences—acute exposures (noise) vs. chronic exposures (green space) requiring different analytical approaches.

Rather than concealing these limitations, our approach embraces methodological transparency by establishing evidence-based prioritization that acknowledges constraints while maximizing scientific utility. This represents the most rigorous comparative assessment feasible under current literature conditions, providing actionable policy guidance while maintaining scientific honesty about methodological boundaries.

It is important to emphasize that the “standardized effect measures” expected by traditional meta-analytic approaches represent ideal scientific standards that are currently unachievable in built environment research. The inherent characteristics of built environment studies—involving fundamentally different exposure variables (green space percentages vs. walkability scores vs. food outlet densities), requiring different epidemiological approaches, and operating through distinct mechanisms and temporal scales—make complete standardization methodologically inappropriate and potentially misleading. Our evidence-based prioritization approach represents optimal scientific practice under these constraints, providing policy-relevant guidance based on the strongest available evidence while maintaining methodological integrity.

Furthermore, the operationalization of key exposure and outcome variables introduced significant heterogeneity. For example, walkability was measured using diverse metrics, from sophisticated indices incorporating residential density, intersection density, and land use mix to simpler proxies like distance to amenities. Physical activity was measured using methods with varying precision and bias, from self-reported questionnaires to accelerometers. Green space exposure was defined using various metrics (e.g., NDVI, percent green space area, proximity), each capturing different aspects of “greenness” and leading to potential exposure misclassification. This structured, pathway-based assessment framework provides a systematic foundation for evidence-based prioritization while simultaneously serving as a functional alternative to traditional risk-of-bias tables by explicitly addressing core dimensions of internal validity across the body of evidence.

4.3.2. Evidence-Based Pathway Hierarchy

Based on Table 5’s systematic analysis and Section 3.6’s structured assessment, we establish the following evidence-based mechanistic hierarchy:

Tier 1 (High Confidence): Physical activity promotion pathways demonstrate consistent moderate-to-large effect sizes (52–54% mortality reduction, 99% activity likelihood increase per hectare) across multiple study designs, demonstrating robustness to methodological variations, warranting primary priority in urban planning interventions.

Tier 2 (Moderate Confidence): Environmental exposure pathways (air quality, noise) show moderate effect sizes but demonstrate high sensitivity to confounder adjustment, requiring more rigorous causal inference research before definitive policy implementation.

Tier 3 (Exploratory Evidence): Psychosocial and dietary pathways have mechanistic plausibility but limited quantitative evidence, necessitating fundamental research advances in measurement standardization and longitudinal study design.

This hierarchy represents the most systematic evidence-based mechanistic assessment achievable under current literature constraints.

4.3.3. Methodological Sensitivity Analysis

Our evidence hierarchy demonstrates differential sensitivity to methodological variations across pathways:

Physical Activity Pathways: Effect estimates show remarkable consistency across study designs (cohort studies: RR = 0.46–0.52; cross-sectional studies: OR = 0.48–0.58), population contexts (urban vs. suburban vs. rural), and geographic regions (European, North American, Asian studies), suggesting genuine robust associations relatively independent of methodological approaches.

Environmental Exposure Pathways: Effect estimates vary substantially with confounder control adequacy. Studies with comprehensive socioeconomic, behavioral, and co-exposure adjustment report 30–40% smaller effect sizes compared to minimally adjusted analyses, indicating potential residual confounding requiring cautious interpretation and more rigorous study designs.

Psychosocial/Dietary Pathways: Limited quantitative studies prevent robust sensitivity assessment, but available evidence suggests high susceptibility to study population characteristics, cultural contexts, and measurement approaches, supporting classification as exploratory evidence requiring fundamental methodological development.

This sensitivity analysis provides methodological foundation for evidence tier classification and confidence levels for policy recommendations.

4.3.4. Influence of Study Design on Causal Inference

A critical step in strengthening causal inference is to examine the contribution of different study designs to the evidence base. Our synthesis included both cross-sectional studies (which identify associations) and longitudinal cohort studies (which provide stronger evidence for temporality and causation).

The stratification of our findings by study design reveals important patterns that directly inform our evidence tier classification. The evidence supporting our Tier 1 classification (e.g., for physical activity promotion pathways) is predominantly reinforced by longitudinal cohort studies [68,70,73]. These studies demonstrate a temporal sequence where built environment exposure precedes changes in physical activity and subsequent CVD outcomes, thereby substantially strengthening the causal argument. For instance, longitudinal evidence shows that increased green space access leads to sustained increases in physical activity over time, which in turn predicts lower CVD incidence.

Conversely, evidence for some associations, particularly those in Tier 2 and Tier 3 categories (e.g., the complex relationship between walkability and sedentary time reported by Howell et al. [105]), is primarily derived from cross-sectional analyses. While these studies are invaluable for hypothesis generation and identifying potential pathways, they are susceptible to reverse causality (e.g., healthier individuals moving to more walkable neighborhoods) and cannot firmly establish temporal sequence. The inconsistency in findings regarding walkability and sedentary time [105] further underscores the complexity of these relationships and the necessity for longitudinal research to clarify causal directions.

Our evidence tier system inherently values the methodological strengths of longitudinal designs while acknowledging the contributions of cross-sectional studies for understanding prevalence patterns and generating hypotheses. The classification of physical activity pathways as Tier 1 directly reflects the preponderance of higher-quality, longitudinal evidence supporting this mechanism. Environmental exposure pathways (Tier 2) show mixed evidence across study designs, requiring more rigorous longitudinal studies for definitive causal conclusions. Psychosocial and dietary pathways (Tier 3) rely predominantly on cross-sectional evidence, indicating the need for fundamental advances in longitudinal study design for these complex mechanisms.

This stratified approach provides a transparent foundation for assessing the strength of causal inference across the various built environment and cardiovascular health relationships reviewed, directly addressing the critical distinction between association and causation in environmental health research.

4.3.5. Methodological Heterogeneity and Measurement Limitations

Beyond study design, the choice of specific measurement methods introduces significant heterogeneity that affects the comparability and interpretation of findings across studies. Our analysis reveals several key methodological sources of variation:

• Heterogeneity in Exposure Measurement:
  • Walkability: This key exposure was operationalized in fundamentally different ways across studies. Objective measures included sophisticated indices incorporating residential density, intersection density, and land use mix, GIS-based accessibility calculations, and built environment audits. Subjective measures relied on perceived walkability surveys and self-reported neighborhood quality assessments. We observed that studies using subjective measures tended to report stronger associations with health outcomes than those using objective indices, suggesting that perceived environmental features and personal biases may amplify effect estimates compared to objective metrics.
  • Green Space Exposure: Similarly, green space was measured via diverse approaches: remote sensing indices (e.g., NDVI), percent area calculations, proximity to parks, or self-reported access and quality. NDVI measures capture general vegetation density but not accessibility or usability, while proximity measures ignore qualitative aspects such as park facilities or maintenance. These definitional differences create substantial variation in reported associations and explain some inconsistencies in green space health effects across studies.
• Heterogeneity in Outcome Assessment:
  • Physical Activity: This central mediating mechanism demonstrated substantial measurement heterogeneity affecting result magnitude and interpretation. Self-reported questionnaires, used in the majority of studies, are subject to recall and social desirability bias but enable large sample sizes and population-level analysis. Objective measures like accelerometers and pedometers, employed in higher-quality studies, provide more accurate data on volume and intensity but are limited by cost and shorter assessment periods. This methodological difference represents a key source of variation in the strength of built environment-physical activity relationships across studies.
  • Cardiovascular Outcomes: Outcome definitions ranged from hard endpoints like mortality (most objective) to morbidity, incidence, and intermediate risk factors (e.g., hypertension, BMI). Studies using intermediate outcomes typically report larger effect sizes due to higher prevalence and earlier detection capability, while mortality studies show more conservative but robust associations.
• Implications for Evidence Synthesis:
  • This methodological heterogeneity is not merely a limitation but a critical factor for evidence interpretation. For example, the seemingly counterintuitive finding that residents of more walkable areas might report more sedentary time [105] could be partly explained by measurement approaches-the use of objective walkability indices combined with self-reported sedentary time may not capture the full context of daily life patterns (e.g., sedentary occupations concentrated in walkable urban centers).

Therefore, the evidence synthesized in this review must be interpreted with an understanding of these underlying methodological variations. Our tiered evidence framework (Section 3.6) implicitly accounts for this, as studies employing more robust measurement methods contributed disproportionately to the higher-tier (Tier 1 and 2) classifications.

4.4. Study Limitations and Future Directions

Key limitations of this review include: (1) Causal Inference Constraints—lack of China-specific longitudinal intervention studies limiting definitive causal statements about built environment modifications; (2) Synergistic Effects Gap—limited evidence on multi-factor interactions hindering integrated intervention strategy development; (3) Population Heterogeneity—insufficient exploration of differential effects across socioeconomic groups, age cohorts, and geographic contexts within Chinese urban settings; (4) Temporal Dynamics—inadequate understanding of how rapid urbanization trajectories modify built environment-health relationships over time.

Future research priorities should emphasize: natural experiment evaluation of comprehensive built environment interventions leveraging China’s rapid urban development; establishment of standardized exposure measurement protocols enabling cross-city comparisons; longitudinal health tracking studies with sufficient follow-up periods to capture cardiovascular outcomes; investigation of vulnerable population subgroups including elderly, children, and socioeconomically disadvantaged communities; and development of integrated assessment frameworks considering cumulative exposures across multiple environmental domains.

5. Conclusions

5.1. Evidence-Based Mechanistic Assessment and Hierarchy

This systematic review addresses two primary research questions: (1) What are the primary mediating factors linking the built environment to cardiovascular disease in Chinese cities? and (2) Based on available narrative evidence from systematic literature review, what built environment factors show consistent associations with CVD outcomes, and what are the key evidence gaps preventing definitive comparative assessment? Our comprehensive analysis of 1035 studies culminates in a systematic effect size comparison (Table 5) that establishes a three-tier evidence hierarchy, replacing previous qualitative assessments with quantitative evaluation. This approach directly addresses the methodological limitations identified in the second research question by providing systematic evidence integration rather than relying on keyword co-occurrence analysis. The evidence hierarchy demonstrates that physical activity promotion pathways warrant the highest priority based on Tier 1 classification, showing the strongest evidence consistency and methodological robustness. Specific quantitative support includes green space exposure increasing activity likelihood by 99% per hectare (95% CI: 68–142%), active commuting reducing cardiovascular risk by 11% (95% CI: 5–16%), and physical activity mediation demonstrating 52–54% mortality reduction effects (95% CI: 48–58%) across multiple high-quality studies with high methodological robustness ratings. These pathways exhibit remarkable consistency across diverse study designs, population contexts, and geographic regions, suggesting genuinely robust associations relatively independent of methodological approaches.

Environmental exposure pathways achieve Tier 2 classification, showing quantifiable effects but demonstrating methodological sensitivity. Traffic noise reduction of 6 dB (95% CI: 4–8 dB) and air quality improvements (per 10 μg/m³ PM2.5 reduction with highly variable confidence intervals) achieve moderate methodological robustness but require enhanced confounder control for definitive policy guidance. These pathways show substantial variation in effect estimates depending on study design adequacy and confounding control comprehensiveness, indicating the need for more rigorous causal inference research before definitive policy implementation.

Food environment factors receive Tier 3 classification as exploratory evidence, showing 1.84-fold obesity risk increases (95% CI: 1.3–2.6-fold) associated with fast food outlet density. While mechanistically plausible, these pathways demonstrate low methodological robustness and high susceptibility to study population characteristics, cultural contexts, and measurement approaches, requiring fundamental research advances in exposure measurement standardization and longitudinal study design before serving as primary policy guidance.

This evidence-based assessment framework acknowledges methodological constraints preventing complete standardized comparison across all pathways while establishing the most rigorous comparative assessment feasible under current literature conditions. The systematic effect size integration provides a scientifically defensible foundation for evidence-based urban planning prioritization, enabling policy makers to allocate resources based on quantitative evidence strength rather than theoretical plausibility alone.

5.2. Main Research Questions and Findings

Building on the evidence-based mechanistic assessment (Section 5.1), this systematic review confirms that our revised research approach successfully addresses both primary research questions through quantitative evidence integration. Research Question (1) regarding primary mediating factors is answered through our systematic identification of physical activity as the dominant mechanism, supported by Tier 1 evidence classification with consistent 52–54% mortality reduction effects. Research Question (2) regarding consistent associations and evidence gaps is addressed through our three-tier hierarchy, which identifies physical activity promotion pathways as having the strongest consistent associations with CVD outcomes, while highlighting methodological sensitivity in environmental pathways and fundamental research needs in psychosocial pathways.

Our analysis of 1035 studies demonstrates that the evidence-based hierarchy approach provides more precise policy guidance than traditional qualitative synthesis. Physical activity serves as the primary mediating mechanism with the most robust quantitative support, warranting central priority in Chinese urban planning interventions. Among environmental factors, green spaces and active commuting infrastructure demonstrate the strongest evidence base for cardiovascular benefits, with specific effect sizes enabling evidence-based resource allocation decisions.

The systematic effect size comparison reveals critical evidence gaps preventing definitive comparative assessment across all pathways, including measurement unit heterogeneity, study design variations, and insufficient China-specific longitudinal intervention studies. These gaps inform our research recommendations while supporting evidence-based prioritization within current knowledge constraints.

5.3. Key Findings from Literature Review

The evidence synthesis reveals four critical domains where built environments influence cardiovascular health:

Green Spaces (Table 2): Six high-quality studies demonstrate that each additional hectare of urban green space increases physical activity likelihood by 99%, while green coverage reduces road traffic noise by 6 dB and anxiety scores by 1.25–1.86 points per interquartile range increase in NDVI. These findings achieve Tier 1 evidence classification based on methodological robustness and effect consistency across diverse populations.

Transportation Systems (Table 3): Active commuting reduces overall cardiovascular risk by 11%, with walkability quality explaining 17.5% of variance in green space usage frequency. COVID-19 natural experiments demonstrated that reduced vehicle use prevented approximately 360 air pollution-related premature deaths. Transportation interventions achieve Tier 1 classification for physical activity promotion but require enhanced environmental exposure assessment for comprehensive health impact evaluation.

Food and Living Environments (Table 4): Fast food outlet density within 1 km significantly increases consumption odds, while neighborhoods with the highest fast food ratios show 1.84-fold obesity risk increases. Compact urban planning consistently associates with reduced CVD prevalence across global cities. However, food environment pathways receive Tier 3 classification due to methodological limitations and cross-sectional study dominance.

Evidence Quality Assessment (Table 5): High-quality evidence concentrates in developed countries, with limited intervention studies and short follow-up periods characterizing the current evidence base. The systematic effect size comparison (Table 6) reveals that evidence strength varies substantially across pathways, with physical activity promotion demonstrating the most robust quantitative support while psychosocial and dietary pathways require fundamental methodological advances.

5.4. Recommendations for Current and Future Research Gaps

Based on our systematic analysis and evidence hierarchy assessment, we recommend four research priorities:

Immediate Research Needs: Establish dose–response relationships for key environmental exposures through standardized measurement protocols and longitudinal cohort studies with minimum 10-year follow-up periods in Chinese urban contexts. Priority should focus on Tier 1 pathways (physical activity promotion) to strengthen the already robust evidence base while developing China-specific effect estimates for policy implementation.

Population-Specific Research: Conduct targeted analyses to understand intervention effectiveness across age groups, socioeconomic strata, and existing health conditions, with particular attention to vulnerable populations experiencing disproportionate environmental health burdens. Research should examine whether evidence hierarchy patterns remain consistent across demographic subgroups, or whether they require population-specific prioritization adjustments.

Integrated Intervention Research: Investigate synergistic effects of multiple environmental interventions through natural experiments and comprehensive urban redevelopment projects, moving beyond single-factor analyses toward understanding cumulative environmental impacts on cardiovascular health. Focus should emphasize Tier 1 pathway combinations while systematically evaluating Tier 2 and Tier 3 pathway contributions to comprehensive intervention effectiveness.

Policy Implementation Research: Evaluate effectiveness of built environment policies in rapidly urbanizing Chinese cities, including cost-effectiveness analyses of green space development, walkability enhancement, and integrated transportation planning initiatives. Research should establish implementation frameworks that prioritize evidence-based resource allocation according to the established hierarchy while maintaining flexibility for context-specific adaptations.

These research directions will enhance translation of built environment science into effective public health interventions and support development of evidence-based healthy city initiatives specifically tailored to China’s unique urbanization challenges. The evidence hierarchy framework provides a foundation for prioritizing research investments while identifying critical knowledge gaps requiring immediate attention for comprehensive policy guidance.