Abstract Body (Do not enter title and authors here): Introduction: Cardiovascular (CV) disease risk factors in rural areas are influenced by behavioral, environmental and social factors. Risk factors begin in childhood and contribute to increased morbidity and mortality in adults.

Research Questions: What is the difference in burden of CV risk factors among pediatric patients by rural and urban residences?

Aims: To describe the CV risk factors among patients 6-17 years of age by rural and urban dwelling in a large, rural health system.

Methods:
Descriptive cohort study of patients aged 6-17 years in the PedsBP study, a pragmatic, cluster-randomized study in 44 Essentia Health (MN, WI, ND) primary care clinics (3 pediatric, 41 family medicine, 73% rural). Patients were included who had an ambulatory clinic visit and blood pressure measurement at time of index visit and were seen from 8/1/2022-7/31/2023. Patients were separated into groups based on rural vs urban residence (rural urban commuting code [RUCA] 4-10 were considered rural). Primary outcomes include the number of CV risk factors (out of 5): hypertension, obesity, pre-diabetes or diabetes mellitus, hyperlipidemia (all based on problem list, labs and vital signs), and current tobacco smoking or passive smoke exposure (self-reported).

Results:
Among 33,160 (50.4% female, mean age 11.6 years, SD=3.5 years) eligible patients,18,348 (55.3%) were from a rural residence. The most common CV risk factor was obesity (Rural N=3,888; 21.2%; Urban N=2,890; 19.5%), followed by current smoking/passive smoking (Rural N=3,341;18.2%; Urban N=2,201; 14.9%), hyperlipidemia (Rural N=548; 3.0%; Urban N=750; 5.1%), hypertension (Rural N=415, 2.3%; Urban N=357; 2.4%), and diabetes (or pre-diabetes) (Rural N=215; 1.2%; Urban N=225; 1.5%). Patients in rural areas were more likely to have ≥1 CV risk factors than patients in urban areas (36.1% vs. 33.6%, p<0.001). However, patients in rural and urban areas did not differ in their likelihood of having ≥2 CV risk factors (8.5% vs. 8.1%, p=0.22).

Conclusions:
1 in 12 children and adolescents have ≥2 CV risk factors. Obesity and smoking are the most prevalent factors. Differences between rural and urban youth varied by risk factor.