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. 2023 Sep 12;136(20):2421–2430. doi: 10.1097/CM9.0000000000002863

Global, regional, and national burden of hypertensive heart disease among older adults in 204 countries and territories between 1990 and 2019: a trend analysis

Ruixue Yang 1, Xun Zhang 1, Jingjing Bai 1, Lu Wang 1, Wenjie Wang 1, Jun Cai 1,✉
Editor: Rongman Jia1
PMCID: PMC10586836  PMID: 37698022

Abstract

Background:

Hypertensive heart disease (HHD) poses a public health challenge, but data on its burden and trends among older adults are scarce. This study aimed to identify trends in the burden of HHD among older adults between 1990 and 2019 at the global, regional, and national levels.

Methods:

Using the Global Burden of Diseases study 2019 data, we assessed HHD prevalence, death, and disability-adjusted life-year (DALY) rates for individuals aged 60–89 years at the global, regional, and national levels and estimated their average annual percentage changes (AAPCs) between 1990 and 2019 using joinpoint regression analysis.

Results:

In 2019, there were 14.35 million HHD prevalent cases, 0.85 million deaths, and 14.56 million DALYs in older adults. Between 1990 and 2019, the prevalence of HHD increased globally {AAPC, 0.38 (95% confidence interval [CI], 0.36, 0.41)} with decreases observed in mortality (AAPC, –0.83 [95% CI, –0.99, –0.66]) and the DALY rate (AAPC, –1.03 [95% CI, –1.19, –0.87]). This overall global trend pattern was essentially maintained for sex, age group, and sociodemographic index (SDI) quintile except for non-significant changes in the prevalence of HHD in those aged 70–74 years and in the middle SDI quintile. Notably, males had a higher HHD prevalence rate. However, HHD-related mortality and the DALY rate were higher in females. The middle SDI quintile experienced the largest decreases in mortality and the DALY rate, with a non-significant decline in prevalence between 1990 and 2019. There were significant discrepancies in the HHD burden and its trends across regions and countries.

Conclusions:

In the past three decades, there has been an overall increasing trend in the prevalence of HHD among older adults worldwide despite decreasing trends in mortality and the DALY rate. Better management of hypertension, and prevention and control of HHD are needed in older adults.

Keywords: Hypertensive heart disease, Hypertension, Prevalence, Mortality, Disability-adjusted life-years, Global burden

Introduction

Hypertension is a leading risk factor for cardiovascular disease and imposes a heavy public health burden worldwide.[1] The number of adults aged 30–79 years with hypertension has doubled globally between 1990 and 2019, with more than one billion cases recorded in 2019.[2] However, the detection, treatment, and control of hypertension remain challenging and vary between regions and nations.[3,4] Poorly controlled or uncontrolled blood pressure increases the risk of hypertensive heart disease (HHD), which is characterized by microscopic and macroscopic cardiac remodeling and functional alterations and accompanied by adaptions of the arterial system.[5]

The pathogenesis of HHD is sequential and complex. In brief, cardiac fibrosis is an integral process in the adaptation to persistent high blood pressure.[5] Interconnected mechanisms involving activated immunity, increased oxidative stress, and worsening endothelial dysfunction also contribute to the pathogenesis of HHD and have been reviewed elsewhere.[5,6] Ultimately, irreversible cardiac remodeling (e.g. left ventricular hypertrophy) facilitates ventricular systolic and diastolic dysfunction, leading to heart failure.[7] In 2017, an estimated 17.1 million population were suffering from HHD worldwide, with 925,675 deaths and 16.5 million disability-adjusted life-years (DALYs).[8] HHD has become the second leading cause of heart failure,[9] and is also the main cause of cardiometabolic death in US adults.[10] As one of the most populous countries in the world, China accounted for more than one-third (36.5%) of the total increase in the global number of prevalent cases of HHD between 1990 and 2017.[8] Overall, HHD poses a public health challenge worldwide, and raising public awareness and improving the management of HHD, especially in vulnerable populations, should now be a global priority.

There has been a rapid expansion of the aging population throughout the world. Individuals older than 60 years accounted for 9.2% of the global population in 1990 and 11.7% of that in 2013, and this figure is projected to increase to 21.1% by 2050.[11] HHD is an age-related disease that is expected to pose an ever-increasing burden in older adults.[12] However, the trends in the burden of HHD among older individuals have not been fully elucidated. An understanding of these trends would be of benefits in terms of prevention and intervention. The aim of this study was to provide updated evidence on the burden of HHD in older adults at the global, regional, and national levels using data from the Global Burden of Disease (GBD) study 2019.

Methods

Study population and data collection

This study analyzed the latest data obtained from the GBD 2019 project (available from https://vizhub.healthdata.org/gbd-results/), which estimated the incidence, prevalence, mortality, and DALYs associated with 369 diseases and injuries and 87 risk factors for 21 regions and 204 countries and territories by age, sex, location, and year between 1990 and 2019.[13,14] Relevant data from censuses, household surveys, disease registries, health service use, civil registration and vital statistics, disease notifications, satellite imaging, air pollution monitors, and other sources were collected and identified for the GBD estimation process.[14] Definition, processing, correction, and modeling of the data have been described elsewhere.[13,14,15]

Our present study focused on global, regional, and national trends in the burden of HHD in older adults aged 60–89 years. Data on the prevalence, mortality, and DALYs associated with HHD were obtained from the Global Health Data Exchange using the GBD results tool (https://vizhub.healthdata.org/gbd-results/). Specifically, HHD data were collected for males, females, and both sexes in seven age groups (60–89, 60–64, 65–69, 70–74, 75–79, 80–84, and 85–89 years) by 21 regions and by 204 countries and territories as defined in the previous GBD project.[14] In GBD 2019, HHD was identified by the International Classification of Diseases code I11-I11.9.[8] The prevalence of HHD was estimated using the DisMod-MR 2.1 model, which is a Bayesian meta-regression tool.[14] Deaths from HHD were modeled using a Bayesian, hierarchical, space-time, ensemble model tool known as the standard Cause of Death Ensemble model (CODEm).[14] DALYs were used to quantify the overall burden attributable to HHD and were defined as the sum of years lived with disability and years of life lost as a result of premature death.[14]

We also extracted the sociodemographic index (SDI) data from GBD 2019. The SDI is a summary measure that demonstrates the social and economic conditions relevant to health outcomes in a given location. This index is calculated based on three components: the total fertility rate in individuals younger than 25 years, lag-distributed income per capita, and mean educational attainment for individuals aged 15 years or older.[16] The SDI scale has a range of 0–1, whereby one represents the highest level of development. All 204 countries and territories in GBD 2019 were categorized into SDI quintiles, namely, low, low-middle, middle, high-middle, and high.[15]

Statistical analysis

This study reports the age-specific rates for prevalence, death, and DALYs per 100,000 population with 95% uncertainty intervals (UIs) based on the 25th and 975th values of 1000 ordered estimates of the posterior distribution.[14]

Temporal trends in the prevalence, mortality, and DALY rate for HHD were determined by calculating their average annual percentage changes (AAPCs) between 1990 and 2019 with 95% confidence intervals (CIs) using the joinpoint regression analysis.[17,18] This analysis can fit the simplest joinpoint model and uses a Monte Carlo permutation method to test for significance when more joinpoints are added to the model, allowing for the identification of points with significant changes in linear trends in either direction or magnitude. The AAPC, which is a weighted average of the annual percentage change (APC) that is calculated for each linear trend segment detected, is proposed to summarize and compare inconstant rates of change over a given period. In this study, the AAPC was used to denote percentage changes annually between 1990 and 2019 (increase, decrease, or no change). Furthermore, we stratified the global trends by sex, age group (60–64, 65–69, 70–74, 75–79, 80–84, and 85–89 years), and SDI quintile. We also collected data on regional and national trends in the prevalence of HHD, mortality, and the DALY rate among older adults aged 60–89 years.

All statistical analyses were performed using R version 4.2.0 (R Foundation for Statistical Computing, Vienna, Austria). Two-sided P-values <0.05 were considered statistically significant.

Results

Global trends

The global trends in prevalence of HHD, mortality, and the DALY rate among adults aged 60–89 years between 1990 and 2019 are shown in Table 1. Overall, the prevalence of HHD increased between 1990 and 2019 (AAPC, 0.38 [95% CI, 0.36, 0.41]). In contrast, mortality and the DALY rate decreased between 1990 and 2019 (mortality, AAPC, –0.83 [95% CI, –0.99, –0.66]; DALY rate, –1.03 [95% CI, –1.19, –0.87]).

Table 1.

Global prevalence, mortality, DALY rate, and their AAPCs of HHD between 1990 and 2019 by sex, age group, SDI quintile, and region.

Items Prevalence Death DALY
1990 rate/ 100,000 (95% UI) 2019 rate/ 100,000 (95% UI) AAPC (95% CI) 1990 rate/100,000 (95% UI) 2019 rate/100,000 (95% UI) AAPC (95% CI) 1990 rate/ 100,000 (95% UI) 2019 rate/ 100,000 (95% UI) AAPC (95% CI)
Global 1263.52 (848.30–1841.30) 1415.94 (970.88–2036.80) 0.38 (0.36, 0.41)* 106.29 (86.82–119.24) 84.27 (63.40–93.05) –0.83 (–0.99, –0.66)* 1925.02 (1576.79–2149.59) 1437.24 (1110.93–1594.74) –1.03 (–1.19, –0.87)*
Sex
Male 1327.87 (887.36–1943.40) 1420.78 (969.89–2064.53) 0.23 (0.20, 0.27)* 98.60 (74.29–110.68) 79.99 (55.82–89.81) –0.73 (–0.83, –0.64)* 1890.07 (1419.52–2123.31) 1431.35 (1045.77–1607.59) –0.97 (–1.06, –0.88)*
Female 1210.66 (821.06–1763.24) 1411.70 (965.98–2017.44) 0.52 (0.50, 0.54)* 112.60 (92.77–137.71) 88.01 (68.65–99.40) –0.85 (–0.94, –0.75)* 1953.72 (1582.94–2346.34) 1442.38 (1165.18–1629.54) –1.05 (–1.15, –0.95)*
Age group
60–64 years 408.54 (225.65–671.60) 456.95 (250.65–743.50) 0.40 (0.35, 0.46)* 37.09 (28.54–42.39) 24.36 (18.36–27.30) –1.44 (–1.56, –1.32)* 1067.84 (824.22–1217.43) 717.01 (546.75–805.84) –1.37 (–1.48, –1.25)*
65–69 years 987.12 (591.03–1583.83) 1042.96 (632.89–1668.13) 0.19 (0.15, 0.24)* 62.66 (47.83–71.18) 39.66 (30.54–44.15) –1.60 (–1.75, –1.46)* 1546.72 (1210.25–1756.35) 1013.07 (803.91–1131.29) –1.49 (–1.63, –1.35)*
70–74 years 1669.36 (969.12–2634.07) 1699.65 (1001.31–2634.98) 0.06 (0, 0.12) 115.88 (90.50–131.39) 70.96 (53.96–79.04) –1.72 (–1.91, –1.53)* 2352.27 (1847.48–2665.51) 1494.16 (1186.50–1674.28) –1.60 (–1.78, –1.41)*
75–79 years 2064.58 (1123.80–3489.00) 2222.11 (1218.55–3698.04) 0.24 (0.21, 0.28)* 177.69 (145.07–200.35) 124.91 (95.08–138.59) –1.22 (–1.32, –1.11)* 2857.01 (2385.72–3217.77) 2064.14 (1631.24–2308.35) –1.12 (–1.21, –1.04)*
80–84 years 2653.98 (1420.84–4541.60) 2893.97 (1535.40–4848.56) 0.27 (0.18, 0.36)* 288.45 (244.61–328.57) 241.73 (181.04–267.03) –0.61 (–0.81, –0.41)* 3568.38 (3042.19–4066.42) 3029.35 (2304.17–3367.67) –0.57 (–0.76, –0.38)*
85–89 years 3858.18 (2261.76–6003.69) 4081.02 (2405.54–6337.99) 0.18 (0.06, 0.30)* 431.42 (362.46–493.79) 413.03 (290.40–460.30) –0.16 (–0.26, –0.06)* 4134.21 (3475.42–4731.16) 3968.70 (2877.46–4436.27) –0.15 (–0.25, –0.05)*
SDI quintile
High 861.92 (582.48–1265.02) 939.86 (648.69–1337.38) 0.29 (0.21, 0.37)* 44.30 (37.03–47.81) 36.65 (29.82–41.51) –0.66 (–0.79, –0.53)* 735.73 (617.13–796.54) 592.57 (504.99–666.95) –0.74 (–0.88, –0.59)*
High-middle 1231.98 (810.21–1850.21) 1492.81 (1000.91–2189.72) 0.67 (0.57, 0.76)* 85.26 (76.80–96.77) 71.53 (55.57–78.67) –0.60 (–0.69, –0.51)* 1497.50 (1353.14–1685.27) 1148.35 (950.12–1277.98) –0.94 (–1.02, –0.86)*
Middle 1953.96 (1323.18–2808.19) 1949.46 (1335.34–2777.39) -0.02 (-0.06, 0.03) 178.55 (123.89–201.16) 113.75 (72.00–128.04) –1.60 (–1.85, –1.36)* 3263.86 (2273.19–3680.52) 1960.91 (1330.92–2195.47) –1.80 (–2.02, –1.58)*
Low-middle 993.10 (665.07–1453.14) 1101.74 (743.28–1610.85) 0.36 (0.33, 0.38)* 120.46 (86.47–148.10) 98.06 (80.86–116.66) –0.69 (–0.91, –0.46)* 2265.79 (1617.75–2746.90) 1729.93 (1442.93–2036.79) –0.95 (–1.18, –0.72)*
Low 1041.01 (672.82–1550.51) 1083.11 (710.73–1590.13) 0.13 (0.11, 0.15)* 164.69 (114.11–226.61) 142.43 (97.39–188.87) –0.51 (–0.57, –0.45)* 3203.97 (2191.76–4294.31) 2613.69 (1820.16–3443.42) –0.70 (–0.76, –0.65)*
Region
Andean Latin America 767.76 (486.93–1172.89) 916.08 (596.40–1366.37) 0.62 (0.60, 0.63)* 73.94 (62.81–84.54) 54.85 (45.11–65.03) –1.07 (–1.30, –0.84)* 1234.03 (1052.34–1402.21) 895.76 (740.63–1062.56) –1.17 (–1.37, –0.96)*
Australasia 693.63 (468.23–1005.00) 519.32 (351.33–743.25) -0.96 (-1.06, -0.86)* 19.07 (14.17–20.86) 12.86 (10.39–16.56) –1.36 (–1.54, –1.18)* 339.24 (263.06–384.72) 213.86 (179.87–274.81) –1.58 (–1.70, –1.45)*
Caribbean 1335.84 (914.83–1966.17) 1321.69 (907.44–1938.47) -0.03 (-0.06, -0.01)* 108.53 (94.62–137.72) 107.98 (88.71–127.76) 0 (–0.16, 0.16) 1982.75 (1720.29–2463.64) 1903.23 (1574.86–2246.46) –0.10 (–0.23, 0.03)
Central Asia 1239.57 (839.89–1781.82) 1033.28 (682.71–1502.31) -0.61 (-0.69, -0.53)* 89.40 (78.00–124.13) 131.58 (110.76–151.03) 1.36 (1.15, 1.57)* 1677.19 (1472.40–2294.85) 2327.44 (1998.78–2703.99) 1.21 (1.06, 1.35)*
Central Europe 1217.24 (791.43–1838.19) 1192.83 (799.92–1754.99) -0.08 (-0.18, 0.02) 111.31 (103.23–139.09) 134.83 (98.35–156.00) 0.63 (0.41, 0.85)* 1900.19 (1769.97–2324.21) 2048.99 (1554.63–2376.25) 0.21 (–0.05, 0.48)
Central Latin America 1004.44 (667.18–1506.64) 991.08 (657.70–1480.27) -0.04 (-0.07, 0)* 95.63 (66.51–102.09) 59.59 (49.72–74.78) –1.66 (–1.87, –1.45)* 1622.03 (1151.02–1733.18) 987.77 (835.55–1253.46) –1.74 (–1.93, –1.54)*
Central Sub-Saharan Africa 790.45 (448.19–1304.41) 802.73 (468.44–1326.15) 0.06 (0.04, 0.08)* 278.77 (180.84–374.31) 268.90 (168.71–363.78) –0.11 (–0.18, –0.05)* 5603.97 (3618.78–7450.97) 4985.50 (3148.23–6797.21) –0.39 (–0.46, –0.32)*
East Asia 2364.10 (1579.84–3484.60) 2438.53 (1646.67–3542.65) 0.10 (0.03, 0.16)* 194.52 (147.51–220.53) 103.17 (65.57–120.37) –2.26 (–2.76, –1.75)* 3528.99 (2632.60–4005.09) 1718.49 (1213.53–1992.89) –2.55 (–2.96, –2.14)*
Eastern Europe 353.30 (224.09–548.48) 376.14 (238.20–587.17) 0.25 (0.09, 0.40)* 18.92 (16.98–33.61) 40.58 (24.47–47.03) 2.75 (1.85, 3.66)* 373.91 (334.96–620.97) 692.31 (445.09–800.33) 2.16 (1.29, 3.03)*
Eastern Sub-Saharan Africa 1510.40 (964.74–2224.07) 1607.25 (1025.34–2341.46) 0.21 (0.16, 0.27)* 252.18 (157.64–371.64) 197.51 (115.05–297.98) –0.83 (–0.92, –0.74)* 4837.39 (3038.91–7002.37) 3574.69 (2146.21–5346.43) –1.04 (–1.09, –0.98)*
High-income Asia Pacific 436.05 (260.67–694.21) 550.69 (353.61–824.97) 0.82 (0.72, 0.92)* 43.59 (25.24–47.25) 18.83 (14.78–27.71) –2.85 (–3.13, –2.57)* 648.51 (414.65–704.02) 279.21 (226.67–423.94) –2.86 (–3.06, –2.66)*
High-income North America 1154.14 (745.25–1746.03) 1322.89 (889.56–1884.81) 0.46 (0.26, 0.66)* 38.36 (30.72–40.31) 38.33 (26.82–41.56) 0.02 (–0.28, 0.32) 719.55 (573.25–801.78) 737.69 (539.12–818.77) 0.10 (–0.05, 0.26)
North Africa and Middle East 1712.19 (1152.73–2520.06) 1827.52 (1275.04–2581.73) 0.23 (0.20, 0.26)* 206.76 (123.98–261.67) 168.59 (90.93–207.16) –0.68 (–0.80, –0.56)* 3762.74 (2298.96–4724.15) 2901.86 (1650.11–3579.73) –0.88 (–1.01, –0.75)*
Oceania 1757.51 (1155.59–2551.41) 1836.47 (1215.42–2677.42) 0.14 (0.06, 0.22)* 145.32 (98.73–194.90) 134.03 (90.35–179.19) –0.29 (–0.39, –0.19)* 3044.31 (2081.93–4098.55) 2753.81 (1890.86–3659.58) –0.35 (–0.43, –0.27)*
South Asia 560.99 (371.21–852.56) 651.41 (430.61–985.64) 0.52 (0.48, 0.56)* 88.12 (53.52–122.32) 67.97 (47.83–89.11) –0.92 (–1.45, –0.38)* 1657.49 (1012.35–2244.24) 1199.13 (862.56–1557.63) –1.15 (–1.64, –0.66)*
Southeast Asia 1909.87 (1311.91–2758.41) 1935.85 (1334.76–2752.24) 0.05 (0.02, 0.07)* 129.74 (93.55–153.81) 115.01 (74.32–129.25) –0.41 (–0.53, –0.30)* 2523.43 (1809.96–2984.02) 2184.27 (1443.29–2461.05) –0.47 (–0.56, –0.39)*
Southern Latin America 1330.42 (861.48–2026.64) 1271.09 (837.96–1934.11) –0.15 (–0.21, –0.09)* 82.96 (74.69–100.99) 80.68 (69.18–95.62) –0.13 (–0.37, 0.11) 1454.24 (1319.19–1688.51) 1256.39 (1097.22–1533.15) –0.51 (–0.78, –0.24)*
Southern Sub-Saharan Africa 963.70 (579.42–1502.53) 865.30 (518.98–1351.08) –0.36 (–0.41, –0.32)* 149.76 (128.36–188.00) 166.53 (147.12–186.39) 0.38 (–0.19, 0.96) 2629.80 (2273.73–3284.65) 2864.46 (2559.63–3212.51) 0.35 (–0.25, 0.95)
Tropical Latin America 1037.91 (685.15–1550.48) 1085.70 (705.93–1641.38) 0.17 (0.13, 0.20)* 111.50 (90.65–119.39) 73.68 (64.67–101.40) –1.40 (–1.58, –1.22)* 2041.81 (1639.38–2185.60) 1274.44 (1137.50–1751.99) –1.60 (–1.76, –1.43)*
Western Europe 840.37 (566.15–1226.73) 960.86 (649.97–1381.66) 0.47 (0.39, 0.55)* 51.45 (44.15–58.80) 52.72 (39.76–59.09) 0.13 (–0.04, 0.29) 791.82 (674.35–874.94) 711.73 (563.81–803.92) –0.36 (–0.56, –0.16)*
Western Sub-Saharan Africa 1278.51 (837.31–1835.30) 1345.58 (871.51–1946.84) 0.17 (0.13, 0.22)* 95.50 (72.11–120.03) 96.58 (59.32–120.21) 0.07 (–0.21, 0.36) 1884.80 (1418.54–2356.66) 1877.31 (1181.79–2341.63) 0.04 (–0.08, 0.17)
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*Statistically significant variables of AAPC (P <0.05). AAPC: Average annual percentage change; CI: Confidence interval; DALY: Disability-adjusted life-year; HHD: Hypertensive heart disease; SDI: Sociodemographic index; UI: Uncertainty interval.

The joinpoint regression analysis identified significant changes in trends [Figure 1]. The prevalence of HHD increased markedly between 1990 and 2009, decreased slightly between 2009 and 2017 (APC –0.12), and then increased dramatically between 2017 and 2019, which was the largest increasing trend (APC 1.53). The HHD-related mortality and DALY rates showed similar trends of a significant decline between 1990 and 2004, no significant change between 2004 and 2007, an increase between 2007 and 2014, and a decrease between 2014 and 2019. In 2019, there were 14.35 million prevalent cases, 0.85 million deaths, and 14.56 million DALYs among individuals aged 60–89 years [Supplementary Table 1, http://links.lww.com/CM9/B741].

Figure 1.

Figure 1

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Joinpoint regression analysis of global prevalence (A), mortality (B), and DALY rate (C) for HHD in individuals aged 60–89 years between 1990 and 2019. *P <0.05. APC: Annual percentage change; DALY: Disability-adjusted life-year; HHD: Hypertensive heart disease.

Global trends by sex

The prevalence of HHD increased globally in both sexes between 1990 and 2019 [Table 1]. However, there were reductions in mortality and the DALY rate between 1990 and 2019 in both sexes. Overall, compared with males, females showed a more pronounced increasing trend in the prevalence of HHD and larger decreases in mortality and the DALY rate.

The joinpoint regression analysis demonstrated substantial changes in trends for prevalence of HHD, mortality, and the DALY rate by sex [Figure 2]. Of note, dramatic increases in the prevalence of HHD were observed between 2017 and 2019 in both sexes (with an APC of 0.93 for males and 2.01 for females). In terms of mortality and the DALY rate, downward trends in females were generally maintained irrespective of fluctuations during the three decades, except for a slight increase in HHD-related mortality between 2004 and 2014 (APC 0.13). In males, the mortality and DALY rate decreased between 1990 and 2007, increased markedly between 2007 and 2014, and decreased between 2014 and 2019.

Figure 2.

Figure 2

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Joinpoint regression analysis of the global prevalence (A), mortality (B), and DALY rate (C) for HHD in individuals aged 60–89 years between 1990 and 2019 by sex. *P <0.05. APC: Annual percentage change; DALY: Disability-adjusted life-year; HHD: Hypertensive heart disease.

Global trends by age group

Global trends in the prevalence of HHD, mortality, and the DALY rate are presented by age group in Table 1. Globally, these rates increased with advancing age, that is, individuals aged 85–89 years had the highest prevalence, mortality, and DALY rate among the older adults in this study. However, individuals aged 60–64 years showed the largest increasing trend in prevalence of HHD between 1990 and 2019 (AAPC, 0.40 [95% CI, 0.35, 0.46]). There was also a significant increase in the prevalence of HHD among individuals in the groups aged 65–69, 75–79, 80–84, and 85–89 years between 1990 and 2019. Notably, there was no significant change in the prevalence of HHD in individuals aged 70–74 years between 1990 and 2019 (AAPC, 0.06 [95% CI, 0, 0.12]). However, this age group showed the most pronounced decreasing trends in mortality from HHD (AAPC, –1.72 [95% CI, –1.91, –1.53]) and DALY rate (AAPC, –1.60 [95% CI, –1.78, –1.41]) between 1990 and 2019, although all age groups experienced substantially decreased HHD-related mortality and DALY rates.

Significant changes in trends identified by the joinpoint regression analysis are presented in Figure 3. Notably, the groups aged 65–69 years, 70–74 years, 75–79 years, and 85–89 years showed their largest increasing trend in prevalence of HHD between 2017 and 2019.

Figure 3.

Figure 3

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Joinpoint regression analysis of global prevalence (A), mortality (B), and DALY rate (C) for HHD in individuals aged 60–89 years between 1990 and 2019 by age group. *P <0.05. APC: Annual percentage change; DALY: Disability-adjusted life-year; HHD: Hypertensive heart disease.

Global trends by SDI

Globally, all SDI regions showed a substantial increasing trend in the prevalence of HHD among individuals aged 60–89 years except for those in the middle SDI quintile, in whom there was no significant change (AAPC, –0.02 [95% CI, –0.06, 0.03]) [Table 1]. Specifically, between 1990 and 2019, the largest increasing trend in prevalence by SDI quintile was observed in the high-middle quintile (AAPC, 0.67 [95% CI, 0.57, 0.76]), followed by the low-middle quintile (AAPC, 0.36 [95% CI, 0.33, 0.38]), high quintile (AAPC, 0.29 [95% CI, 0.21, 0.37]), and low quintile (AAPC, 0.13 [95% CI, 0.11, 0.15]). In contrast, all SDI regions showed reductions in mortality and the DALY rate [Table 1], with the most pronounced downward trend seen in the middle SDI quintile (mortality, AAPC, –1.60 [95% CI, –1.85, –1.36]; DALY rate, –1.80 [95% CI, –2.02, –1.58]).

There were fluctuations in trends in prevalence, mortality, and the DALY rate over the three decades [Figure 4]. Notably, mortality from HHD decreased dramatically in the middle SDI quintile between 1990 and 2004 (APC –3.16 in 1990–2001; –3.98 in 2001–2004), decreased (albeit not significantly) in 2004–2007, increased substantially in 2007–2014 (APC 1.74), and then declined in 2014–2019 (APC –1.71). In 2019, the low SDI quintile had the highest HHD-related mortality, followed by the middle, low-middle, high-middle, and high quintiles. The trend in the DALY rate by SDI quintile followed a pattern similar to that for mortality.

Figure 4.

Figure 4

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Joinpoint regression analysis of global prevalence (A), mortality (B), and DALY rate (C) for HHD in individuals aged 60–89 years between 1990 and 2019 by SDI quintile. *P <0.05. APC: Annual percentage change; DALY: Disability-adjusted life-year; HHD: Hypertensive heart disease; SDI: Sociodemographic index.

Regional trends

The HHD burden and trends between 1990 and 2019 at the regional level are shown in Table 1. The largest increase in the prevalence of HHD between 1990 and 2019 was observed in the high-income Asia Pacific (AAPC, 0.82 [95% CI, 0.72, 0.92]), Andean Latin America (AAPC, 0.62 [95% CI, 0.60, 0.63]), and South Asia (AAPC, 0.52 [95% CI, 0.48, 0.56]). In contrast, the largest decrease in the prevalence of HHD between 1990 and 2019 was in Australasia (AAPC, –0.96 [95% CI, –1.06, –0.86]), Central Asia (AAPC, –0.61 [95% CI, –0.69, –0.53]), and Southern Sub-Saharan Africa (AAPC, –0.36 [95% CI, –0.41, –0.32]).

The three regions with the largest increases in HHD-related mortality between 1990 and 2019 were Eastern Europe (AAPC, 2.75 [95% CI, 1.85, 3.66]), Central Asia (AAPC, 1.36 [95% CI, 1.15, 1.57]), and Central Europe (AAPC, 0.63 [95% CI, 0.41, 0.85]). Only two regions (Eastern Europe and Central Asia) showed significant increasing trends in the DALY rate between 1990 and 2019. Conversely, three regions (the high-income Asia Pacific, East Asia, and Central Latin America) experienced the largest decreases in both mortality and the DALY rate.

In 2019, East Asia had the largest number of prevalent cases of HHD (6.42 million), followed by Southeast Asia (1.37 million) and South Asia (1.09 million) [Supplementary Table 1, http://links.lww.com/CM9/B741]. The three regions with the most deaths were East Asia (0.27 million), South Asia (0.11 million), and North Africa and Middle East (0.08 million). The most DALYs were recorded in East Asia (4.52 million), followed by South Asia (2.00 million) and Southeast Asia (1.55 million) [Supplementary Table 1, http://links.lww.com/CM9/B741].

National trends

HHD burden at the national level in 2019 and their AAPCs between 1990 and 2019 are presented in Supplementary Tables 2 and 3, http://links.lww.com/CM9/B741. Overall, there were 85 countries with a significant increasing trend in prevalence of HHD and 81 with a significant decreasing trend between 1990 and 2019. Bolivia (Plurinational State of), Italy, and Cameroon were the three countries with the largest increasing trend in the prevalence of HHD. In contrast, Canada had the largest decrease in the prevalence of HHD, followed by Austria and France.

Estonia had the largest increasing trend in mortality between 1990 and 2019, followed by Latvia and the Republic of Moldova. The largest decreasing trends were observed in Israel, Guam, and Qatar. In terms of the DALY rate, the largest increasing trends between 1990 and 2019 were observed in Estonia, Latvia, and the Republic of Moldova, with the largest decreasing trends occurring in Israel, Guam, and the Republic of Korea.

In 2019, China had the largest number of HHD cases and the most deaths and DALYs worldwide [Supplementary Tables 3 and 4, http://links.lww.com/CM9/B741]. Overall, the prevalence of HHD increased slightly in China between 1990 and 2019 (AAPC, 0.09 [95% CI, 0.03, 0.15]), while mortality and the DALY rate decreased sharply during this period (mortality, AAPC, –2.30 [95% CI, –2.82, –1.78]; DALY rate, –2.59 [95% CI, –3.02, –2.16]). As shown in the joinpoint regression analysis [Supplementary Figure 1, http://links.lww.com/CM9/B741], a sharp increase in the prevalence of HHD has been observed since 2017 (APC, 3.33). Mortality and the DALY rate have shown similar trends in the past three decades, with marked downward trends in 1990–2007, sharp increases in 2007–2013, and relatively slow decreasing trends since 2013. There are also sex discrepancies regarding the prevalence, mortality, and DALY rate of HHD in the older population in China [Supplementary Figure 2, http://links.lww.com/CM9/B741].

Discussion

This study provides a comprehensive understanding of trends in the prevalence of HHD and the associated mortality and DALY rate in adults aged 60–89 years between 1990 and 2019 at the global, regional, and national levels. Our findings show that in 2019, there were 14.35 million prevalent cases of HHD, 0.85 million deaths, and 14.56 million DALYs among individuals aged 60–89 years. There was an overall increase in the global prevalence of HHD and decrease in mortality and the DALY rate between 1990 and 2019. This overall global trend pattern was essentially maintained for both sexes and in all age groups between 60 and 89 years and SDI quintiles except for non-significant changes in the prevalence of HHD in the group aged 70–74 years and in the middle SDI quintile. We also observed significant discrepancies in the HHD burden and its trends across regions and countries.

HHD remains a major concern in the management of hypertension and an important public health challenge.[7,19] According to the GBD 2017 data, the number of individuals with HHD worldwide increased by more than 2-fold between 1990 and 2017, reaching 17.1 million with 925,675 deaths and 16.5 million DALYs.[8] These data have continued to increase globally, with 19.6 million prevalent cases, 1.16 million deaths, and 21.5 million DALYs in 2019.[20] However, although the burden of HHD derives mainly from the older population, detailed information regarding the HHD burden and its trends in this population has been scarce. Our present findings help to fill this gap and add important evidence in support of the need for the prevention and control of HHD. We found an overall increasing trend in the prevalence of HHD in the elderly in 1990–2019, which is consistent with the overall trend in the global population across all age groups,[8,20] and may be explained by improved detection of HHD, relatively poor management of hypertension, and increased life expectancy coupled with rapid population aging. Conversely, HHD-related mortality and the DALY rate decreased, suggesting that prevention and treatment of HHD among older adults in the past three decades has had some degrees of positive effects globally. Notably, we observed the largest increasing trend in the prevalence of HHD since 2017 with a slowing of decreasing trends in HHD-related mortality and the DALY rate since 2014. This finding suggests that we are presently facing even more rapid growth of the burden of HHD, which needs urgent attention.

We observed that the age-specific prevalence rate of HHD was higher in males than in females. There are several possible reasons for this discrepancy. First, the burden attributed to high systolic blood pressure (SBP) was greater in males aged 60–89 years in 2019 worldwide.[21] Second, males tend to have less health awareness, lower compliance, and more undesirable health behaviors, such as smoking and poor dietary habits, which increase the risk of HHD,[22] and may contribute to their higher prevalence of the disease. However, HHD-related mortality and the DALY rate were higher in females. There is evidence of secondary prevention being less common in females than in males,[23] suggesting less effective management of cardiovascular disease in females, which contributes to a worse prognosis and a higher mortality rate.[24] This may explain the higher HHD mortality and DALY rate in females. Notably, the overall increasing trend in prevalence of HHD was greater in females, with a sharp increase since 2017. Consequently, the difference in prevalence of HHD between the sexes has become smaller over time. Overall, our findings highlight disparities in the disease burden between the sexes, and the burden of HHD in older females should not be ignored.

The burden of HHD increases with age in older adults, which highlights the fact that HHD is an age-related disease,[12] and coincides with the burden of high SBP.[21] Interestingly, individuals aged 70–74 years had the largest decreases in mortality and the DALY rate between 1990 and 2019, with a non-significant increase in the prevalence of HHD. We attempted to find explanations for these findings. According to the latest trends reported by the World Health Organization, the global life expectancy increased from 66.8 years in 2000 to 73.3 years in 2019.[25] The rapid increase in the population aged 70–74 years along with improved medical resources and living conditions in the past few decades may have contributed to the rapid downward trend of HHD-related mortality and DALYs. However, given that studies on age-related differences in the burden of HHD in older adults are scarce, more investigations are warranted to explore the cause.

We also found variation in the burden of HHD according to the SDI quintile. In this analysis, the high SDI quintile showed relatively good control of HHD and had the lowest prevalence, mortality, and DALY rate despite slowing in reduction of the HHD-related mortality and the DALY rate across the years. Of note, the highest prevalence rate of HHD was observed in the middle SDI quintile. Hypertension has become the leading risk factor for cardiovascular disease in middle-income countries.[26,27] The middle SDI quintile has consistently experienced a particularly heavy and increasing burden of high SBP.[21] The heavy burden of hypertension, low control rate, and limited health care resources in addition to an aging population may impose a heavy burden of HHD among older adults in the middle SDI quintile. However, this quintile had the largest decreasing trends for HHD-related mortality and the DALY rate, which is attributed to rapid urbanization with improvements in health care services and education. In contrast, the low SDI quintile currently has the highest mortality and DALY rate, which is consistent with earlier research showing that cardiovascular event and death rates are higher in low-income countries than in high-income and middle-income countries.[27] Many individuals in the low SDI quintile are at high cardiovascular risk as a result of poor diet and environmental factors,[1,28] as well as limited access to and acceptance of cardiovascular medication.[29] Without the strong support of socioeconomic development and appropriate policy and health care systems, a high disease burden in the older population represents a substantial loss of productivity and more pressure on health and long-term care systems, especially in low-income countries.[30] Overall, the burden of HHD is greater among the elderly in the low and middle SDI quintiles. However, there has been limited research on the prevention and management of HHD in older adults in these quintiles, and more investigations tailored to local conditions in these SDI regions are warranted to decrease the burden of HHD. Furthermore, intensive concerted efforts by governments, physicians, schools, and families are required to improve the management of hypertension in the low and middle SDI quintiles, achieve efficient health care delivery, and improve access to affordable health insurance to control HHD.

Temporal trends in HHD among older adults varied markedly across the 21 regions and 204 countries and territories. At the regional level, there was a trend of increasing prevalence of HHD in 14 regions. The largest increase in prevalence was seen in the high-income Asia Pacific (Japan, Singapore, Republic of Korea, Brunei Darussalam), which may be attributed to an aging society and westernization of lifestyle. However, this region had the largest decreases in mortality and the DALY rate, implying successful management of HHD by control of risk factors, improved universal health coverage, and adequate health literacy.[1,31] In contrast, Australasia showed the largest downward trend in the prevalence of HHD, which reflects a significant decrease in the burden attributed to high SBP.[21] At the national level in 2019, China had the largest number of HHD cases as well as the most HHD-related deaths and DALYs in older adults worldwide. In the past three decades, the prevalence of HHD in China has shown small fluctuations in amplitude but has increased rapidly since 2017, indicating that more efforts are needed in terms of the management of hypertension and prevention of HHD. The trend patterns of HHD-related mortality and DALY rates were similar to those at the global level; however, the overall decreasing trends between 1990 and 2019 were more pronounced in China, reflecting the considerable advances made in medical treatment and socioeconomic status in this country. Notably, there is a discrepancy in the sex distribution of the burden of HHD in China and at the global level. In recent years, the prevalence of HHD has been higher in older females than in older males in China, suggesting an urgent need to prevent this disease in older females. In the meantime, males had worse HHD-related mortality and a higher DALY rate, which may be attributed to their poorer health awareness and lifestyle habits. These differences between males and females emphasize the importance of targeted interventions based on sex. The central government of China has released the Healthy China 2030 plan, which includes policies and strategies to improve the overall health of the Chinese population by 2030,[32] one of which focuses on disease prevention. Our findings regarding the burden of HHD in older adults in China will help in the development of evidence-based policies regarding HHD. Overall, there are gaps in the prevention, management, and treatment of HHD worldwide. Our findings regarding the current situation of HHD and its temporal trends highlight inequities in the burden of HHD among older adults globally as well as a need for public health interventions at the individual and population levels.[33]

Our findings shed light on the burden of HHD among adults aged 60–89 years and may help to guide the prevention and control of this disease. In recent years, novel insight has been gained into the pathophysiology and diagnosis of HHD.[7,19] Beyond left ventricular hypertrophy, a spectrum of target-organ damage has been identified to play an important role in the development of HHD.[5] Indeed, left ventricular hypertrophy was found to be present in only around one-third of individuals in a pooled cohort of 37,700 treated and untreated hypertensive patients.[34] Furthermore, innovative diagnostic approaches based on imaging and circulating biomarkers and supplemented with artificial intelligence applications and machine learning have been investigated to identify hypertensive patients with distinct myocardial remodeling phenotypes who are at higher risk of HHD.[19] Notably, the management of blood pressure is the cornerstone for the prevention of HHD and control of its burden. Following the successful SPRINT trial,[35] intensive blood pressure lowering to <130 mmHg was recommended in the 2017 guideline for management of hypertension published by the American College of Cardiology/American Heart Association.[36] The recent STEP trial confirmed that intensive lowering of SBP had cardiovascular benefits in older patients with hypertension in China.[37] However, it continues to be challenging to improve the awareness, treatment, and control of hypertension, especially in older adults, and there is a need for more research on the treatment of HHD in this vulnerable population.

This study has some limitations. First, its results relied on GBD 2019 data, which came from a large number of sources of varying quality. Several factors, including data sources and their collation and analysis, may have introduced bias. However, considerable effort was made by the GBD collaborators to correct for known bias and ensure the quality of the data.[14] Second, we could not describe the relevant demographic, clinical, or laboratory data for HHD in detail because this information was not included in GBD 2019.

In summary, among older adults aged 60–89 years, the prevalence of HHD has increased globally whereas mortality and the DALY rate have decreased. The trends in the burden of HHD over time have varied according to sex, age group, SDI quintile, region, and nation. Our findings underscore the urgent need for the prevention and treatment of HHD in older people and for locally tailored approaches to lessen the disparity in this burden between countries.

Acknowledgements

We are incredibly grateful to those who have contributed to the GBD 2019 in various capacities. We thank Liwen Bianji (Edanz) for the language polishing of a draft of this manuscript.

Funding

This study was supported by the CAMS Innovation Fund for Medical Sciences (CIFMS, 2021-I2M-1-007), the National Natural Science Foundation of China (Project No. 81825002), and the Beijing Outstanding Young Scientist Program (Project No. BJJWZYJH01201910023029).

Conflicts of interest

None.

Supplementary Material

cm9-136-2421-s001.docx (508.9KB, docx)
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Footnotes

Ruixue Yang and Xun Zhang contributed equally to this work.

How to cite this article: Yang RX, Zhang X, Bai JJ, Wang L, Wang WJ, Cai J. Global, regional, and national burden of hypertensive heart disease among older adults in 204 countries and territories between 1990 and 2019: a trend analysis. Chin Med J 2023;136:2421–2430. doi: 10.1097/CM9.0000000000002863

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