Background <p>Heart failure (HF) continues to be a public health issue in China with population aging and increasing disease drivers. The burden, spatial patterns, temporal trends, and underlying causes of HF in China at subnational levels remain inadequately understood. This study aims to assess the disease burden and causes of HF, and their regional disparities in China from 1990 to 2023.</p> Methods <p>Utilizing the estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we assessed the prevalence and years lived with disability (YLDs) of HF and their trends in China at both national and subnational levels. Estimates were also compared by disease severity, sex, age group, cause, and region.</p> Results <p>In 2023, China had an estimated 14.3 million HF cases, marking a significant 208.4% increase over the past three decades. Ischemic heart disease (IHD) has become the top cause of HF, compared with 1990, with hypertensive heart disease (HHD) at the top. Alongside chronic obstructive pulmonary disease (COPD), these three leading causes accounted for 77.4% of all HF cases. The burden of HF due to IHD and COPD exhibited distinct regional patterns and substantial disparities: regions in northern China exhibited notably higher age-standardized YLDs rates for HF due to IHD, while provinces in the western regions faced the highest burden from COPD. Six provinces with the highest tertile of YLDs rates in 2023 also experienced the most pronounced increases between 1990 and 2023.</p> Conclusions <p>HF remains a significant public health challenge in China, with a marked increase in prevalence over the past three decades. The substantial regional variations highlight the need for targeted and region-specific public health strategies. Enhanced nationwide efforts should be made to reduce the geographical disparities in the burden of HF.</p>