OBJECTIVE: To describe the relationship between cardiovascular disease (CVD) risk factors and health-related social needs (HRSN) among youth 6 to 17 years receiving care in a primarily rural health system. METHODS: Cross-sectional study of patients 6 to 17 years who were eligible for a pragmatic, cluster-randomized clinical trial. Patients with a blood pressure (BP) measurement at a primary care visit between August 1, 2022 to July 31, 2023 were included. Primary measures were CVD risk factors, identified through diagnoses, problem lists and clinical data, and the presence of one or more HRSN as reported in a validated questionnaire. Contingency tables and logistic regression analyses were used to quantify associations between CVD risk factors and HRSN. RESULTS: A total of 33,192 patients (mean 11.6 years, 49.6% male, 55.3% rural) were included. Smoking, obesity, and BP were routinely assessed, while diabetes and dyslipidemia were evaluated in a subset. Thirty-five percent had at least 1 CVD risk factor. Obesity (21.0%) and smoking or passive smoke exposure (16.8%) occurred frequently, while diabetes or prediabetes (3.0%) and hypertension or hypertensive level blood pressure (2.3%) were infrequent. Financial strain (4.0%), food worry (3.3%), and food insecurity (2.4%) were the most often reported HRSN. Having an HRSN was associated with CVD risk factors, including smoking (adjusted odds ratio [aOR]: 2.59; 95% confidence interval [CI]: 2.25-2.99), diabetes or prediabetes (aOR, 1.57; 95% CI: 1.01-2.43), and obesity (aOR, 1.63; 95% CI: 1.41-1.88). CONCLUSIONS: We found a high proportion of youth with increased CVD risk. Self-reported HRSN were associated with CVD risk factors, including smoking, diabetes or prediabetes, and obesity.