This cross-sectional study uses the normalized difference vegetation index and the soil-adjusted vegetation index to examine the associations between the level of residential greenness, the presence of cardiometabolic disorders, and the prevalence of cardiovascular disease among adults in China.Question Is the general vegetation level of a residential area, referred to as residential greenness, associated with cardiovascular disease among adults, and does the presence of cardiometabolic disorders mediate or modify the association between residential greenness and cardiovascular disease? Findings In this cross-sectional study of 2445 adults in China, residential areas with higher greenness levels were associated with a lower likelihood of cardiovascular disease. The presence of cardiometabolic disorders partially mediated the association between residential greenness and cardiovascular disease. Meaning The study's findings may be helpful for health care professionals and policy makers in the development of strategies, such as planning for green spaces in residential areas, to mitigate the burden of cardiovascular disease.Importance Living in areas with more vegetation (referred to as residential greenness) may be associated with cardiovascular disease (CVD), but little data are available from low- and middle-income countries. In addition, it remains unclear whether the presence of cardiometabolic disorders modifies or mediates the association between residential greenness and CVD. Objective To evaluate the associations between residential greenness, cardiometabolic disorders, and CVD prevalence among adults in China. Design, Setting, and Participants This analysis was performed as part of the 33 Communities Chinese Health Study, a large population-based cross-sectional study that was conducted in 33 communities (ranging from 0.25-0.64 km(2)) in 3 cities within the Liaoning province of northeastern China between April 1 and December 31, 2009. Participants included adults aged 18 to 74 years who had resided in the study area for 5 years or more. Greenness levels surrounding each participant's residential community were assessed using the normalized difference vegetation index and the soil-adjusted vegetation index from 2010. Lifetime CVD status (including myocardial infarction, heart failure, coronary heart disease, cerebral thrombosis, cerebral hemorrhage, cerebral embolism, and subarachnoid hemorrhage) was defined as a self-report of a physician diagnosis of CVD at the time of the survey. Cardiometabolic disorders, including hypertension, diabetes, dyslipidemia, and overweight or obese status, were measured and defined clinically. Generalized linear mixed models were used to evaluate the association between residential greenness levels and CVD prevalence. A 3-way decomposition method was used to explore whether the presence of cardiometabolic disorders mediated or modified the association between residential greenness and CVD. Data were analyzed from October 10 to May 30, 2020. Main Outcomes and Measures Lifetime CVD status, the presence of cardiometabolic disorders, and residential greenness level. Results Among 24 845 participants, the mean (SD) age was 45.6 (13.3) years, and 12661 participants (51.0%) were men. A total of 1006 participants (4.1%) reported having a diagnosis of CVD. An interquartile range (1-IQR) increase in the normalized difference vegetation index within 500 m of a community was associated with a 27% lower likelihood (odds ratio [OR], 0.73; 95% CI, 0.65-0.83; P < .001) of CVD prevalence, and an IQR increase in the soil-adjusted vegetation index within 500 m of a community was associated with a 26% lower likelihood (OR, 0.74; 95% CI, 0.66-0.84; P < .001) of CVD prevalence. The presence of cardiometabolic disorders was found to mediate the association between residential greenness and CVD, with mediation effects of 4.5% for hypertension, 4.1% for type 2 diabetes, 3.1% for overweight or obese status, 12.7% for hypercholesterolemia, 8.7% for hypertriglyceridemia, and 11.1% for high low-density lipoprotein cholesterol levels. Conclusions and Relevance In this cross-sectional study, higher residential greenness levels were associated with lower CVD prevalence, and this association may be partially mediated by the presence of cardiometabolic disorders. Further studies, preferably longitudinal, are warranted to confirm these findings.