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Objective To estimate decadal trends in the prevalence of metabolic syndrome (MetS) in economically developed regions in China and its association with city economic levels. Methods Using a comprehensive Chinese healthcare database, repeated cross-sectional studies were conducted on adults who had annual health check-ups from 2012 to 2021 in 4 economically developed cities. MetS was defined by the criteria of the Chinese Diabetes Society in 2013. The crude prevalence of MetS adjusted for sex and age was reported. The association between prevalence, calendar year, and city gross domestic product (GDP) per capita was analyzed by regression model. Results 158 274 participants aged 18 years and older were included. The unadjusted prevalence of MetS increased from 15.5% (95% CI: 14.2%-16.8%) to 20.0% (95% CI: 19.5%-20.5%) from 2012 to 2021. The adjusted overall prevalence has increased steadily from 12.8% to 20.8% after controlling age and sex (P <.001). Male and older age groups had a higher MetS prevalence. In the regression model of the association between the MetS prevalence, calendar year, and city GDP per capita, calendar year had a positive association with the prevalence (P <.001, 95% CI: 0.648-1.954) and city GDP per capita had a negative association (P =.030, 95% CI: −0.136 to −0.007). Conclusion The MetS prevalence increased steadily in the economically developed regions in China among the health check-up population during 2012-2021. The MetS prevalence is shown to be negatively associated with GDP per capita in the study population. [ABSTRACT FROM AUTHOR]