Importance: Cardiovascular disease is the leading cause of death in the United States but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously. Objective: To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 including risk factors driving these changes. Design: CVD mortality, nonfatal health outcomes and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 using standardized approaches for data processing and statistical modeling. Burden of disease was estimated by for 10 groupings of CVD and comparative risk analysis was performed. Setting: United States of America Exposures: US states and the District of Columbia Main Outcome: CVD Disability-adjusted Life Years Results: Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. CVD DALYs remained twice as large among men as women. 3 Ischemic heart disease was the leading cause of CVD DALYs in all states but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol, high fasting plasma glucose, tobacco smoking and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggests additional unmeasured risk beyond these traditional factors. Conclusions and Relevance: Large disparities in total burden of CVD persist between US states despite marked improvements in cardiovascular disease burden. Differences in CVD burden is largely attributable to modifiable risk exposures.