Global, regional and national burden of ischemic heart disease and its attributable risk factors from 1990 to 2021: a systematic analysis of the Global Burden of Disease study 2021

Abstract

Background

Ischemic heart disease (IHD) continues to be the foremost contributor to global morbidity and mortality. This analysis aims to report an updated assessment of prevalence, deaths, and disability-adjusted life years (DALYs) due to IHD and its attributable risk factors in 204 countries and territories from 1990 to 2021, by age, sex, and socio-demographic index (SDI).

Methods

This analysis used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021. IHD was defined as acute myocardial infarction, chronic stable angina, chronic IHD, and heart failure due to IHD. Major indicators used in this study were prevalence, death and DALYs. All estimates were reported as absolute counts and age-standardized rates per 100,000 population, along with their 95% uncertainty intervals (UIs).

Results

Globally, IHD accounted for 254.3 (95%UI: 221.4 to 295.5) million prevalent cases, 9.0 (95%UI: 8.3 to 9.5) million deaths and 188.4 (95%UI: 177.0 to 198.1) million DALYs in 2021. There was a noticeable decline in the global age-standardized death rate (ASDR) [-31.6% (95%UI: -34.9 to -28.3)] and age-standardized DALYs (ASRDALYs) [-28.8% (95%UI: -32.5 to -25.2)] from 1990 to 2021, with an estimated annual percentage change of -1.3 (95%CI: -1.34 to -1.26) and − 1.2 (95%CI: -1.25 to -1.16), respectively. In 2021, the global prevalence, death, and DALY rates of IHD were higher among males across all age groups, while death and DALY rates reaching a peak in the oldest group for both sexes. Regionally, we found a nonlinear but negative association between age-standardized prevalence rate (ASPR) and SDI. Nationally, similar negative associations were observed between ASRDALYs and SDI. High systolic blood pressure and high low-density lipoprotein cholesterol were the factors contributing most to the deaths and DALYs due to IHD.

Conclusions

Despite declining global age-standardized death and DALYs rates of IHD, sustained multilevel prevention strategies remain essential. This requires population-wide risk factor reduction, targeted interventions for high-risk populations, and strengthened community healthcare networks to ensure accessible, guideline-based management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-025-05022-x.

Background

Ischemic heart disease (IHD), a leading cause of global morbidity and mortality, is a condition characterized by reduced blood flow to the heart muscle due to narrowed coronary arteries, primarily caused by atherosclerosis [1, 2]. Over the past three decades, IHD has remained the most common cause of global deaths and age-standardized death rate (ASDR) and the second most common cause of disability-adjusted life-years (DALYs) for all ages and sexes combined [3, 4]. A wide range of risk factors are associated with IHD, including high systolic blood pressure (SBP), high low-density lipoprotein cholesterol (LDL-C), high fasting plasma glucose (FPG), high body mass index (BMI), smoking, dietary risks, and air pollution [5, 6]. These factors contribute to the development and progression of IHD through various mechanisms, such as oxidative stress [7], endothelial dysfunction, inflammation [8], and thrombosis [9]. Despite significant progress made in medical technology and public health initiatives, there is still an urgent need for effective prevention and management strategies for IHD.

Since the early 1990s, the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study has systematically and comprehensively estimated the global health status and health loss for different age groups, regions, and sexes. GBD study is a multinational collaborative research which provides comprehensive data on incidence, prevalence, death and summary measures of health, such as DALYs of various diseases for every country in the world [3]. Previous studies have primarily utilized data from GBD 2019 and before to analyze the disease burden and trends of IHD at global [10], regional [11], and national [12-14] levels. Some analyses have focused on specific age groups, such as young adults [15], or specific risk factors [6] for IHD burden analysis. To the best of our knowledge, no recent study has comprehensively analyzed the IHD burden and its attributable risk factors at global, regional, and national levels using the GBD 2021 database. Therefore, the updated information on IHD is needed for public health and advocacy purposes.

This study aims to report the global, regional, and national prevalence, deaths, and DALYs due to IHD, and its attributable risk factors from 1990 to 2021, stratified by age, sex, and socio-demographic index(SDI). Hopefully, these findings will provide critical insights to guide the development of targeted prevention strategies and inform global health policies aimed at reducing the burden of IHD and addressing health disparities worldwide.

Methods

Data sources

This study used data from the GBD 2021 database. The GBD 2021 provides estimates for 371 diseases and injuries across 204 countries and territories, including prevalence, incidence, deaths, years lived with disability (YLDs), years of life lost (YLLs), DALYs, and healthy life expectancy. The data covers 25 age groups, and is presented for females, males, and both sexes combined, spanning the years from 1990 to 2021 [4]. The study complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) [16]. As this study is a secondary analysis of data from GBD 2021, no original data was collected. Its accuracy may be affected by the methods of original data collection, reporting differences and modeling assumptions. It is crucial to carefully consider these factors when interpreting the study results.

Case definition

In the GBD 2021 study, IHD was defined according to the International Classification of Diseases, 10th Revision (ICD-10), representing acute myocardial infarction, chronic stable angina, chronic IHD, and heart failure due to IHD. Myocardial infarction was defined according to the Fourth Universal Definition of Myocardial Infarction. Stable angina was defined according to the Rose Angina Questionnaire. The cause of death for each case will be categorized into the GBD cause of death category based on the coding from the ICD-10 [2, 3].

Study indicators

The major indicators used in this study were prevalence, death and DALYs. The prevalence rate of IHD refers to the proportion of individuals in the total population who have IHD during the observation period. The death rate of IHD refers to the proportion of individuals in the population who died from IHD within the observation period. YLDs represents the years of life lost due to disability caused by diseases. YLLs represents the years of life lost due to premature death caused by diseases. DALYs is the sum of YLDs and YLLs, serving as a comprehensive measure that combines the quantity and quality of life in terms of time [17]. In order to ensure the comparability between populations with different demographic profiles, the age-standardized prevalence rate (ASPR), age-standardized death rate (ASDR) and age-standardized DALYs (ASRDALYs) were used in this study [18].

To better understand the relationship between IHD burden and socioeconomic factors, we used the SDI, which is a composite measure of lag-distributed income per capita, average years of education for those aged 15 years or older, and fertility rates among females younger than 25 year [19]. In GBD 2021, Countries were classified into 5 SDI levels (low, low-middle, middle, high-middle, high) to demonstrate their socioeconomic differences. The stratification by SDI integrates economic condition, education level, and population structure, which can more accurately describe the association between socio-demographic development level and health outcomes in different regions compared with income-only classification.

The percentage of deaths and DALYs due to 88 risk factors for IHD were calculated, representative examples included high SBP, high LDL-C, smoking, high FPG, high BMI, ambient particulate matter pollution, and household air pollution from solid fuels. Details on the definitions of these risk factors are provided elsewhere [5].

Data analysis

In the GBD estimation framework, Cause of death ensemble modelling (CODEm) was used to model deaths from IHD, based on vital registration and verbal autopsy data. CODEm was conducted by sex and separately in regions and countries with and without complete vital registration data to reduce the potential for uncertainty inflation due to highly heterogeneous data [4]. The nonfatal estimation of IHD burden was modeled using DisMod-MR 2.1,which is a Bayesian meta-regression disease-modelling tool. The tool provides measures for areas with missing original data by estimating measures for the five cascades of the geographical hierarchy of GBD. Epidemiological data from higher ranked areas were used as priors for epidemiological parameter estimates from lower ranked areas. For areas with missing data, the tool also used location-level covariates to inform prevalence [4]. The GBD study also used uncertainty intervals (UIs) to address missing data. Uncertainty was propagated by sampling 1000 draws at each computational step, which takes into account the differences in calculation methods across countries, as well as the uncertainty from multiple imputations of missing data, which was calculated through a correlation matrix with repeated sampling. UIs were defined as the 2.5th and 97.5th values of the ordered draws. For percentage changes, 95% UI not overlapping zero is considered to be significant. The estimation method of IHD has been described in detail elsewhere [10].

All estimates were reported as absolute counts and age-standardized rates (ASRs) per 100,000 population, along with their 95% UIs. To assess temporal trends in disease burden, we employed the estimated annual percentage change (EAPC). EAPC was derived from the formula: , where β is the coefficient of the time variable estimated through a log-linear regression model.

Pearson’s correlation test was used to analyze the correlation between ASRs (i.e. ASPR, ASDR and ASRDALYs) and SDI. Because three related hypotheses were tested, multiplicity was addressed with the Bonferroni procedure (m = 3). P value < 0.05/3 after correction of multiple tests is considered to be significant.

The proportion of disease burden attributable to the risk factors is quantified by the product of the population attributable fraction and the DALYs or deaths associated with the outcome. Two Bayesian models (spatiotemporal Gaussian process regression and DisMod-MR 2.1) were used to estimate levels of exposure. Mediation factors were estimated to correct overestimation due to multiple risks overlap. The detailed steps of relevant data collection and estimation are described elsewhere [5].

All statistical analyses and data visualization were conducted using R (version 4.1.2).

Patient and public involvement

Patients and the public were not involved in this study.

Clinical trial number

Not applicable.

Results

Global level

In 2021, 254.3 (95%UI: 221.4 to 295.5) million prevalent cases of IHD were reported globally, with an ASR of 2946.4 (95%UI: 2572.7 to 3424.3) per 100 000, which increased 1.4% (95%UI: −2.6 to 5.9) since 1990. IHD accounted for 8991.6 (95%UI: 8264.1 to 9531.1) thousand deaths globally in 2021, with an ASR of 108.7 (95%UI: 99.6 to 115.4) per 100 000, a decrease of 31.6% (95%UI: −34.9 to −28.3) since 1990. The number of DALYs for IHD globally in 2021 was 188.4 (95%UI: 177.0 to 198.2) million, with an ASR of 2212.2 (95%UI: 2075.5 to 2327.6) per 100 000, a decrease of 28.8% (95%UI: −32.5 to −25.2) since 1990 (see Table 1).

Table 1.

Prevalence, deaths, and DALYs for IHD in 2021 and percentage change in ASRs from 1990 to 2021

	Prevalence (95% UI)			Deaths (95% UI)			DALYs (95%UI)
Location	No. in millions (95%UI)	ASRs per 100,000 (95%UI)	Percentage change in ASRs from 1990 to 2021 (95% UI)	No. in thousands (95%UI)	ASRs per 100,000 (95%UI)	Percentage change in ASRs from 1990 to 2021 (95% UI)	No. in thousands (95%UI)	ASRs per 100,000 (95%UI)	Percentage change in ASRs from 1990 to 2021 (95% UI)
Global	254.3(221.4,295.5)	2946.4(2572.7,3424.3)	1.4(−2.6,5.9)	8991.6(8264.1,9531.1)	108.7(99.6,115.4)	−31.6(−34.9,−28.3)	188360.6 (177036.9,198154.5)	2212.2 (2075.5,2327.6)	−28.8(−32.5,−25.2)
High-income Asia Pacific	3.8(3.3,4.5)	821.7(714.6,948.3)	−15.1(−19.4,−10.9)	152.7(124,168.8)	25.6(21.8,27.6)	−61.9(−63.8,−60.4)	2313.1 (2010.8,2492.5)	493 (446.9,520.2)	−57.7(−59,−56.5)
High-income North America	9.8(8.3,11.5)	1494.6(1280.2,1746.9)	−47.6(−50,−44.8)	534.8(468.4,571.5)	75.8(67.2,80.6)	−57.3(−58.4,−56.4)	9426.9 (8621.7,9884.6)	1461.9 (1350.5,1526.2)	−56.3(−57.3,−55.4)
Western Europe	13.3(11.7,15.2)	1480.1(1305.9,1679.6)	−24.0(−27.6,−19.8)	543(464,584.3)	47.3(41.4,50.4)	−68.1(−69.9,−67.1)	8262.2 (7385.9,8764.8)	843.8 (775.3,886.1)	−69.2(−70.4,−68.3)
Australasia	1.1(0.9,1.2)	1967(1749.7,2225.9)	−19.8(−25.4,−14.6)	28.6(24.4,31)	46.7(40.2,50.2)	−73.6(−75.3,−72.4)	446.2 (400.2,474.2)	812.7 (739.3,858.4)	−74.9(−76.2,−73.8)
Andean Latin America	1.3(1.2,1.5)	2236.3(1992.5,2499.7)	9.5(4.2,14.8)	33(28,39.4)	58.2(49.6,69.3)	−37.4(−46.4,−26.6)	681.8 (578.4,811.7)	1150.6 (976.7,1369.6)	−38.1(−47.6,−27)
Tropical Latin America	5.1(4.3,6)	1978(1672.4,2325)	1.2(−2.7,5.4)	162.3(149.1,170.3)	64.5(59,67.8)	−52.6(−54.2,−50.8)	3817.7 (3591.2,3962.6)	1476.1 (1385.5,1533.2)	−49.1(−50.8,−47.1)
Central Latin America	6.6(5.7,7.5)	2625.2(2306.3,2997.2)	−2.6(−6.2,1.3)	247.1(221.2,273.2)	103.7(92.5,114.6)	−17.5(−24.9,−9.3)	5014.8 (4523.5,5572.8)	2017 (1821.5,2238.3)	−17.5(−25.6,−8.6)
Southern Latin America	1.3(1.2,1.5)	1538.9(1388.1,1718.6)	−14.8(−19.1,−10.3)	49.1(45,51.7)	54.4(50.1,57.3)	−63.6(−65.1,−62.3)	931 (877.9,968.4)	1070.9 (1012.6,1113.2)	−62.0(−63.3,−60.8)
Caribbean	1.7(1.5,1.9)	3184(2862,3542.8)	0.1(−4.5,4.3)	61.4(54.9,69)	112.5(100.5,126.5)	−40.5(−46.8,−34.1)	1291.4 (1138,1470.7)	2397.8 (2112.3,2730.4)	−35.6(−43.2,−27.4)
Central Europe	7.1(6.2,8)	3192.9(2824.4,3571.8)	−15.2(−17.9,−11.9)	331.3(299.9,352.6)	140(126.8,148.9)	−48.6(−51.6,−45.8)	5524.2 (5103.8,5888)	2471.2 (2288.2,2635.4)	−52.5(−55.4,−49.5)
Eastern Europe	17.4(15.1,20.5)	4942.6(4299.1,5766.8)	9.1(4.4,14.3)	903.6(811.1,990.6)	252.9(227,277.2)	−21.7(−28.1,−15.2)	16349.3 (14850.2,17851.8)	4687.7 (4267.8,5115.7)	−21.3(−27.9,−14.6)
Central Asia	3.4(3.1,3.7)	4408.4(4040.6,4801.1)	7.6(4.2,11.3)	175.4(159.2,192.4)	265.5(240.7,290.4)	−17.1(−24.5,−10.2)	3674.6 (3323.9,4049.5)	4864.5 (4415.5,5338.7)	−21.6(−29.1,−14.3)
North Africa and Middle East	28.4(25.9,31.3)	6404.8(5872,7041.1)	−0.5(−4.2,3.3)	769.1(685.4,858.3)	202.8(180.6,223.7)	−26.3(−32.6,−19.3)	18148.6 (16140.2,20526.1)	4023.2 (3581.7,4507.5)	−30.2(−37.1,−22.7)
South Asia	64.3(54.2,76.4)	4455.7(3796.7,5339.2)	6.8(2.2,12.2)	1990.1(1824.5,2155.7)	149.1(137,161.2)	9.3(−2.2,23.3)	50666.1 (46308,54713.6)	3351.1 (3075.4,3616.4)	2.3(−9,15.1)
Southeast Asia	12.9(11.3,14.7)	2088.4(1847.4,2376.7)	4.3(0.7,7.7)	638.7(575.9,694.1)	110.9(100.2,120.2)	−3.3(−14.7,9.9)	15931.2 (14296.7,17482.7)	2415.6 (2177.9,2635.3)	−5.2(−16.5,7)
East Asia	65.4(55.7,78.4)	3031.2(2597.7,3606.2)	19.6(13.7,26.7)	2008(1684,2335.2)	108.9(91.2,125.8)	15.9(−2.6,38.1)	36,780 (30982.6,42822.7)	1839.9 (1541.2,2135.3)	3.9(−13.9,26.4)
Oceania	0.2(0.2,0.2)	2912.1(2623.8,3229.7)	3.6(−0.9,8.3)	11.1(9.3,13.3)	170.9(145.4,201.2)	−6.4(−20.2,10)	327 (270,393.5)	3962.8 (3323.2,4723.7)	−7(−22.1,13.5)
Western Sub-Saharan Africa	5(4.3,5.7)	2624.7(2284.5,3000.4)	9.4(5.7,13.4)	161.3(140,185.4)	106(92.8,120.2)	0.6(−12.8,19.5)	3809.7 (3233.2,4452)	2029 (1760.4,2334.1)	−2.6(−16.3,16.7)
Eastern Sub-Saharan Africa	3.7(3.2,4.2)	2224.9(1931.9,2554.4)	5.2(1.3,9.6)	101.2(87.7,117.3)	72.2(62.1,83)	3.9(−12.6,21.1)	2710.7 (2345.6,3122.2)	1536.6 (1333.1,1773.9)	−1.3(−17.5,16)
Central Sub-Saharan Africa	1.1(1,1.3)	2151.8(1934.1,2416.5)	−5.4(−10.5,−0.4)	49.8(38.9,63.7)	119.3(93.7,150.3)	−11.5(−29.1,9.1)	1296.1 (1001.6,1666.4)	2433.1 (1902.5,3100.8)	−13.6(−31.8,8.3)
Southern Sub-Saharan Africa	1.6(1.3,1.8)	2780.7(2387.2,3277.9)	−2.7(−6.7,1.5)	39.8(36.8,43.2)	83.4(76.9,90.2)	9.8(0.1,27.2)	957.9 (887.4,1042.4)	1689.5 (1565.1,1832.2)	3.9(−5.2,18.4)

Generated from data available from https://vizhub.healthdata.org/gbd-results/

DALYs Disability-adjusted life years, IHD Ischemic heart disease, ASRs Age-standardized rates, UI Uncertainty interval

Regional level

In 2021, North Africa and Middle East, Eastern Europe, and South Asia had the highest ASPR per 100,000 for IHD, whereas High-income Asia Pacific, Western Europe, and High-income North America had the lowest. For deaths, Central Asia, Eastern Europe, and North Africa and Middle East had the highest ASDR, whereas High-income Asia Pacific, Australasia, and Western Europe had the lowest. Central Asia, Eastern Europe, and North Africa and Middle East had the highest ASRDALYs, whereas High-income Asia Pacific, Australasia, and Western Europe had the lowest (see Table 1).

From 1990 to 2021, the largest increases in the ASPR for IHD were found in East Asia, Andean Latin America, Western Sub-Saharan Africa, with the largest decreases found in High-income North America, Western Europe, and Australasia. Most regions showed a decrease in the ASDR for IHD, except for East Asia, Southern Sub-Saharan Africa, South Asia, Eastern Sub-Saharan Africa, and Western Sub-Saharan Africa. The greatest decreases were seen in Australasia, Western Europe, and Southern Latin America. The ASRDALYs decreased in nearly all regions from 1990 to 2021, except for East Asia, Southern Sub-Saharan Africa, and South Asia, with the greatest decreases in Australasia, Western Europe, and Southern Latin America (see Table 1).

National level

In 2021, the national ASPR of IHD ranged from 802.3 to 7806.4 cases per 100,000, with Kuwait, United Arab Emirates, and Saudi Arabia had the highest and Japan, Republic of Korea, and Brunei Darussalam had the lowest (see Fig. 1; Additional file 1, Table S1). The national ASDR of IHD ranged from 23.2 to 432.6 deaths per 100,000. The highest rates were found in Nauru, Ukraine, and Syrian Arab Republic, whereas San Marino, Japan, and Republic of Korea had the lowest (see Fig. 2; Additional file 1, Table S2). For DALYs, the national ASRDALYs varied from 429.1 to 7189.7 per 100 000, with the highest rates found in Nauru, Vanuatu, and Egypt, and the lowest found in San Marino, Republic of Korea, and Japan (see Fig. 3; Additional file 1, Table S3).

Fig. 1.

ASPR per 100,000 population of IHD in 2021, by country. Notes: ASPR, age-standardized prevalence rate; IHD, ischemic heart disease. (Generated from data available from https://vizhub.healthdata.org/gbd-results/)

Fig. 2.

ASDR per 100,000 population of IHD in 2021, by country. Notes: ASDR, age-standardized death rate; IHD, ischemic heart disease. (Generated from data available from https://vizhub.healthdata.org/gbd-results/)

Fig. 3.

ASRDALYs per 100,000 population of IHD in 2021, by country. Notes: ASRDALYs, age-standardized disability-adjusted life years; IHD, ischemic heart disease. (Generated from data available from https://vizhub.healthdata.org/gbd-results/)

From 1990 to 2021, great differences in the changes of ASPR, ASDR and ASRDALYs were observed among different countries. For ASPR, Uzbekistan, United Republic of Tanzania, and China had the largest increases, whereas United States of America, Finland, and Canada had the largest decreases (see Additional file 1, Table S1). Over the same period, Lesotho, Cabo Verde, and Kenya had the greatest increases in the ASDR, whereas the greatest decreases were found in Denmark, Israel, Ireland, and Norway (see Additional file 1, Table S2). Lesotho, Zimbabwe, and Cabo Verde had the largest increases in the ASRDALYs of IHD. In contrast, the greatest decreases were found in Denmark, Israel, and Norway (see Additional file 1, Table S3).

Temporal trends

Globally, the ASPR showed minimal variation from 1990 to 2021, with an EAPC of 0 (95%CI: −0.02 to 0.03), though a slight increase emerged during 2019 to 2021. In contrast, both ASDR and ASRDALYs exhibited consistent downward trends, with EAPCs of −1.3 (95%CI: −1.34 to −1.26) and − 1.2 (95%CI: −1.25 to −1.16), respectively (see Fig. 4; Additional file 1, Table S4). As for SDI level, high SDI (see Additional file 1, Figure S1) and high-middle SDI (see Additional file 1, Figure S2) regions showed steady declines in ASPR, ASDR, and ASRDALYs, with the most pronounced reductions observed in high-SDI regions. Middle SDI region experienced declining ASDR and ASRDALYs but rising ASPR (see Additional file 1, Figure S3). In low-middle SDI (see Additional file 1, Figure S4) and low SDI regions (see Additional file 1, Figure S5), all metrics remained stable or showed slight increases except for ASRDALYs in low SDI region, which declined. Among 21 GBD regions, High-income North America exhibited the greatest ASPR decline, while Australasia showed the most rapid reductions in ASDR and ASRDALYs. However, East Asia recorded the fastest increases in ASPR, ASDR, and ASRDALYs (see Additional file 1, Table S4).

Fig. 4.

Temporal trends of the global burden of IHD. Notes: A ASPR (per 100,000) by sex from 1990 to 2021. B ASDR (per 100,000) by sex from 1990 to 2021. C ASRDALYs (per 100,000) by sex from 1990 to 2021. IHD, ischemic heart disease; ASPR, age-standardized prevalence rate; ASDR, age-standardized death rate; ASRDALYs, age-standardized disability-adjusted life years. (Generated from data available from https://vizhub.healthdata.org/gbd-results/)

We further conducted analyses of the change of IHD burden from 2019 to 2021. Globally, while the ASPR of IHD remained stable from 1990 to 2019, the aforementioned 1.4% increase was predominantly attributable to the rebound from 2019 to 2021 (see Additional file 1, Table S5). Concurrently, both ASDR and ASRDALYs demonstrated decreases (see Additional file 1, Table S6-S7). From 2019 to 2021, some countries showed trends that differed from the overall changes of their three-decade patterns (1990–2021). For instance, while East Asia experienced a 15.9% ASDR increase over three decades, it demonstrated a 16% decrease from 2019 to 2021 (see Additional file 1, Table S6). In contrast, Seychelles achieved a 40.0% ASRDALYs decrease since 1990, yet experienced a 7.1% increase compared to 2019 levels (see Additional file 1, Table S7).

Age and sex patterns

In 2021, the global prevalence rate of IHD generally increased with advancing age. The number of prevalent cases was highest in the 65–69 age group. As for sex patterns, prevalence rates were higher among males across all age groups, while the number of prevalent cases was higher in males up to 75–79 age group (see Additional file 1, Figure S6). Global death rate of IHD increased with advancing age, reaching peak levels in the oldest age group (≥ 95 years). The total death cases peaked in the 80–84 age group. The death rates were higher in males than females across all age groups, while the number of death cases was also higher in males up to 75–79 age group (see Additional file 1, Figure S7). Similarly, the global DALYs rate of IHD increased up to the oldest age group (≥ 95 years). The rate was higher in males across all age groups. Also, the number of DALYs peaked in the 65–69 age groups and was higher in males up to 75–79 age group (see Fig. 5).

Fig. 5.

Number of DALYs and DALYs per 100,000 population of IHD, by age and sex in 2021, globally. Notes: Lines indicate DALYs with 95% UI for male and female. DALYs, disability-adjusted life years; UI, uncertainty interval; IHD, ischemic heart disease. (Generated from data available from https://vizhub.healthdata.org/gbd-results/)

Association with SDI

Regionally, we found a nonlinear but significantly negative association between ASPR and SDI [R = −0.16 (−0.23 to −0.09), p < 0.001, significant after correction for multiplicity], with the most predominant decline observed after an SDI of 0.7. The global ASPR was basically in line with expectations. However, North Africa and Middle East, South Asia, Eastern Europe, Central Asia, and Central Europe had higher than expected prevalence burden from 1990 to 2021 (see Fig. 6). The association between ASDR and SDI (see Additional file 1, Figure S8), as well as between ASRDALYs and SDI (see Additional file 1, Figure S9) were not significant, but the highest burden were also observed at an SDI of 0.7. Nationally, nonlinear but significantly negative associations were found between the ASRDALYs and SDI [R = −0.2 (−0.33 to −0.07), p = 0.004, significant after correction for multiplicity] (see Additional file 1, Figure S10), reaching a peak at an SDI of approximately 0.55. The association between ASDR and SDI (see Additional file 1, Figure S11), as well as between ASPR and SDI (see Additional file 1, Figure S12) were not significant. Countries such as Nauru, Egypt, Syria, and Ukraine had much higher than expected burdens, whereas countries like Portugal, Chile, and Spain had much lower than expected burdens (see Additional file 1, Figure S10-S12).

Fig. 6.

ASPR of IHD for global and the 21 GBD regions by SDI, 1990 to 2021. Notes: Thirty-two points are plotted for each region and show the observed ASPR from 1990 to 2021 for that region. Expected values, based on SDI and disease rates in all locations, are shown as a solid line. Regions above the solid line represent a higher than expected burden (e.g. South Asia) and regions below the line show a lower than expected burden (e.g. Southern Latin America). ASPR, age-standardized prevalence rate; IHD, ischemic heart disease; SDI, socio-demographic index. (Generated from data available from https://vizhub.healthdata.org/gbd-results/)

Risk factors

Globally and across 21 GBD regions, high SBP (49.9% for DALYs and 52.2% for deaths) and high LDL cholesterol (35.4% for DALYs and 30.1% for deaths) emerged as the two major risk factors contributing to IHD-related DALYs and deaths in 2021. The proportional contributions of other risk factors exhibited marked geographical heterogeneity. For example, quite large proportion of DALYs and deaths due to IHD in Asia and Africa were attributed to ambient particulate matter pollution and household air pollution from solid fuels. However, in many high-SDI regions, smoking and high BMI were major contributors to DALYs due to IHD, while high FPG contributed more to deaths (see Fig. 7; Additional file 1, Figure S13).

Fig. 7.

Percentage of DALYs due to IHD attributable to each risk factor in 2021. Notes: DALYs, disability-adjusted life years; IHD, ischemic heart disease. (Generated from data available from https://vizhub.healthdata.org/gbd-results/)

Discussion

This study conducted a comprehensive analysis of IHD burden across 204 countries and territories using the GBD 2021 database. In 2021, IHD remained a major global health concern with 254.3 million cases, around 9 million deaths, and 188.4 million DALYs, accompanied by high ASPR, ASDR, and ASRDALYs. While global ASPR remained stable overall, both ASDR and ASRDALYs showed consistent declines, indicating the rise in IHD burden might be associated with population growth and aging [20]. It also exhibited overall improvement in global acute care and secondary prevention. However, the medical sectors must not overlook the rising healthcare demand this brought.

Regarding ASPR trends of IHD, whereas GBD 2019 analyses reported a 4.6% decline in global ASPR from 1990 to 2019 [10], our analysis showed minimal change during this period, possibly due to database algorithm updates and missing data declarations [4], highlighting the need for data renewal. Furthermore, we observed a 1.4% ASPR increase between 2019 and 2021. Notably, The COVID-19 pandemic broke out in 2019. We infer that the increase of ASPR may be related to the global epidemic of COVID-19. Many existing literatures have reported that SARS-CoV-2 infection has long-term effects on the human body, including cardiovascular effects. It increases the risk of cardiovascular disease by mechanisms such as cardiomyocyte invasion, arrhythmia, acute coronary syndrome [21], endothelial inflammation, thrombosis [22] and systemic inflammatory response [23]. Also, the risk of acute ischemic events is increased within few weeks following COVID-19 infection [24]. During the pandemic, lockdown measures and economic stresses may have disrupted chronic disease management, delayed medical consultations [25, 26] and led to unhealthy lifestyle changes [27], which may also negatively impact cardiovascular health. However, the GBD 2021 database does not allow for the direct assessment of the causal impact of COVID-19 on IHD prevalence. Future research with more specific data and longitudinal follow-up will be needed to investigate the direct and indirect effects of COVID − 19 on IHD burden.

At the regional level, great disparities persisted in the burden of IHD across different regions. High-burden regions such as North Africa and the Middle East, Eastern Europe, and Central Asia and low-burden regions such as High-income Asia Pacific, Western Europe, and Australasia consisted with previous studies [2, 10]. These disparities might reflect systemic inequalities in metabolic risks, environmental exposures, and healthcare system capacity across regions. Notably, while most regions showed declining trends of IHD burden, East Asia showed the greatest increase in ASPR, ASDR, and ASRDALYs. This means that East Asia had faced multiple challenges including high exposure to risk factors, limited access to comprehensive healthcare and shortcomings in cardiovascular disease management. The trend underscored the urgent need for policies focusing on targeted risk factor control, optimizing acute care infrastructure (e.g. chest pain center networks), strengthening secondary prevention protocols, and establishing integrated multi-disease management frameworks to improve current conditions. Fortunately, we observed a significant decline in East Asia’s ASDR and ASRDALYs from 2019 to 2021, which might be related to the effective implementation of relevant policies and healthcare system optimization.

We further analyzed the IHD burden across countries, finding significant differences in disease burden changes. Countries such as Lesotho, Cabo Verde, and Zimbabwe, still bore a heavy disease burden of IHD, indicating the overall backwardness of IHD management measures. Nauru, despite normative prevalence rates, had the highest ASDR and ASRDALYs, possibly due to poor medical resources, lack of early identification methods and immature intervention measures. The international community must urgently address these geographical disparities and focus on high-burden countries. For these countries, it is necessary to strengthen the construction of primary medical institutions and the training of primary doctors, optimize the distribution of medical resources, and improve the accessibility of medical care and drugs. The government should strengthen the monitoring of IHD, timely grasp the changes of disease epidemiology, formulate prevention and control strategies and carry out public health education. Finally, these countries can actively seek international assistance and learn from advanced experience to cope with health challenges. We’ve detailed the disease burden of IHD and its changes for each country in tables and figures. Country-specific IHD burden data is crucial for local prevention and control strategies, as reliance on global or regional data may not capture target population nuances.

Our study also analyzed age and sex patterns of IHD burden globally. Males had overall higher burden than females, possibly due to behavioral factors like higher smoking rates. However, we observed a recent increase in female IHD prevalence. Tracy and colleagues [11] reported that in some low-income countries, IHD mortality improvement of females lagged behind males. This might be related to female-specific cardiovascular risk factors like pregnancy and oral contraceptive use [28], accompanied by a higher incidence of obesity [29]. These findings suggest the need for targeted prevention programs to control sex-specific risk factors. All rates except for prevalence of male rose with age, peaking in the oldest group, which showed an aging trend compared to previous study [10]. Regarding case numbers, male predominance persisted until the age of 80, beyond which female predominance emerged, probably due to the life expectancy gap of male and female [30]. These findings suggest targeted measures for the elderly in the context of population aging and highlight the ongoing challenge of reducing the male IHD burden, with a focus on controlling modifiable risk factors like smoking cessation initiatives.

Regional and national economic development greatly impacts disease progression. Thus, we further analyzed the correlation between IHD disease burden and the SDI, a marker of socioeconomic development. In general, we found negative correlations between IHD burden and SDI at both regional and national level. Regions with higher SDI generally had lower IHD burden, aligning with the observed burden reduction patterns in high SDI and high-middle SDI regions. Conversely, regions below median SDI thresholds faced greater challenges which required prioritized interventions. This may result from combined factors like industrialization, urbanization [31], lifestyle differences [32], and population genetic susceptibility [33]. Although the global IHD burden was around the expected value, significant regional differences made the global burden unrepresentative. Therefore, focusing on region-specific and country-specific IHD burden is crucial for localized strategies. For instance, Oceania had a lower than expected ASPR, yet the ASDR and ASRDALYs were both higher than expected, calling for enhanced acute care and secondary prevention strategies. The international community should also prioritize and act on regions and countries with much higher than expected IHD burden.

Shi and colleagues [34] forecast an ongoing rise in the global IHD burden by 2050, with prevalence, deaths, and DALYs reaching 510 million, 16 million, and 302 million respectively. The burden will remain high in regions with rather low SDI level, with males more affected. Notably, Premature death will be severe. While population aging and healthcare improvements made the elderly still the focused age group, studies showed a significant rise in premature deaths in developing regions over the past 30 years [6]. This trend will lead to long-term risk factor exposure and higher cumulative disease burden. There are gaps in addressing premature deaths among countries [35]. Regions with lower SDI should strengthen interventions for middle-aged high-risk individuals, implement universal preventive measures in early stages of IHD, prevent people from risk factors, and ensure access to affordable medicines [36].

Finally, we identified major risk factors for IHD-related deaths and DALYs globally and across 21 GBD regions. Consistent with previous studies, metabolic risk remained the primary risk factor [37, 38]. High SBP and high LDL-C levels were consistently the top two risk factors in all regions. There were also studies showing that in high-SDI regions, the highest proportion of risk factors for DALYs due to IHD in adolescents and young adults is high LDL-C levels [15]. Other key risk factors included air pollution, smoking, high FPG, high BMI, and dietary factors, with significant regional variations. In less developed regions such as Asia and Africa, air pollution emerged as the third-largest risk factor, calling for better control of it. In developed regions, smoking, overweight, and high blood glucose remained major concerns but with reduced proportions compared to 2019 [10]. Regarding diet, diet low in whole grains accounted for a larger proportion than other dietary factors. Recent studies have analyzed the IHD burden related to specific risk factors like smoking [39] and impaired kidney function [40], showing an overall downward trend but with regional disparities persisting. These identified risk factors offer a basis for targeted IHD prevention and control. Regions should adopt diverse prioritized measures. Important public measures include tobacco control, promoting healthy diets, encouraging physical activity, and managing environmental and household air pollution. Managing hypertension, hypercholesterolemia, and diabetes according to guidelines are also crucial [41–43].Recently, measures against tobacco [44] and air pollution [45, 46] in many regions had been proven effective. Future efforts should promote these measures to other regions and countries, especially in areas with high IHD burden.

Strengths and limitations

To the best of our knowledge, this is the first comprehensive analysis of the global, regional and national burden of IHD from 1990 to 2021 based on the GBD 2021 database. We reported the IHD prevalence, deaths, and DALYs, identified age and sex patterns along with key risk factors. Furthermore, we analyzed and displayed the correlation between IHD burden and SDI, offering solid evidence for future targeted IHD prevention and control strategies. Since our analysis entirely relied on the GBD 2021 database, certain limitations must be acknowledged. Firstly, GBD estimations rely on available input data quality, which may vary significantly between countries, especially in low SDI regions. Since this study is a secondary analysis of GBD 2021, results must be carefully interpreted due to the complex modelling techniques the GBD study used to address reporting differences and missing data. Secondly, the shift from ICD-9 to ICD-10 during the study period might have slightly impacted statistical accuracy [47, 48]. Thirdly, the observational nature of the study made it difficult to identify specific causes for disparities. Finally, more detailed forms of IHD weren’t differentiated in GBD classification system, limiting more detailed research. Despite these limitations, this study offers new insights based on the latest available data, presenting evidence in reducing the global IHD burden and addressing health inequality worldwide.

Conclusion

Ischemic heart disease remains a major public health challenge. Globally, age-standardized death rates and DALYs for IHD have declined since 1990, while the age-standardized prevalence rate has increased from 2019 to 2021. Significant disparities exists among regions and countries. Certain areas with IHD burden much higher than expected should be urgently noticed. The IHD burden showed a nonlinear but generally negative association with SDI level. Metabolic risks are still the main factors for deaths and DALYs due to IHD. Sustained multilevel prevention strategies are needed to lower the IHD burden and address health disparities worldwide. This requires population-wide risk factor reduction, targeted interventions for high-risk populations, and strengthened community healthcare networks to ensure accessible, guideline-based management.

Abbreviations

IHD

Ischemic heart disease

GBD

Global Burden of Diseases, Injuries, and Risk Factors

DALYs

Disability-adjusted life-years

YLDs

Years lived with disability

YLLs

Years of life lost

ASRs

Age-standardized rates

ASPR

Age-standardized prevalence rate

ASDR

Age-standardized death rate

ASRDALYs

Age-standardized DALYs

EAPC

Estimated annual percentage change

SDI

Socio-demographic index

CI

Confidence interval

UI

Uncertainty interval

SBP

Systolic blood pressure

LDL-C

Low-density lipoprotein cholesterol

FPG

Fasting plasma glucose

BMI

Body mass index

Authors’ contributions

All authors have directly accessed and verified the underlying data reported in this study. LY, YG, and BZ conceived the study. LY collected and analyzed the raw data, prepared tables and figures, and drafted the original manuscript. YG and BZ contributed to the verification and interpretation of the data, reviewed and edited the manuscript. All authors reviewed the article, read the final manuscript and approved the submission.

Funding

None.

Data availability

This study used data from the GBD 2021 database. The GBD 2021 database was available online from https://vizhub.healthdata.org/gbd-results/.

Declarations

Ethics approval and consent to participate

Ethical approval and informed consent were not required because the GBD study is publicly available and no identifable information was included in the analyses.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.