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International Journal of Cardiology. Cardiovascular Risk and Prevention logoLink to International Journal of Cardiology. Cardiovascular Risk and Prevention
. 2025 Dec 18;28:200565. doi: 10.1016/j.ijcrp.2025.200565

Global burden of non-rheumatic calcific aortic valve disease in adults aged 60 years and older, with projections to 2041: insights from the Global Burden of Disease Study 2021

Jie Tan a,b,1, Xiaoqing Fu a,1, Xiaoqi Li b,1, Xiaorui Zhao a,1, Wenqi Huang c,1, Jing Huang b,⁎, Li Xu c,⁎⁎
PMCID: PMC12811547  PMID: 41550125

Abstract

Background

This study aimed to explore the most recent trends in NRCAVD burden among adults aged 60 years and older and to further predict trends up to 2041.

Methods

We estimated the age-standardized incidence (ASIR), prevalence (ASPR), disability-adjusted life years (DALYs) (ASDALYsR) and death rates (ASDR) of NRCAVD in adults aged ≥60 years from 1990 to 2021 using data from the 2021 Global Burden of Disease Study. Temporal trends were quantified using average annual percent change and projections to 2041 were made using the Nordpred model.

Results

Globally, in 2021, NRCAVD affected 11.78 million older adults (ASPR: 1122.7/100,000), with 0.84 million new cases (ASIR: 77.3/100,000), resulting in 132,764 deaths (ASDR: 13.7/100,000) and an ASDALYsR of 182 per 100,000. From 1990 to 2021, global ASIR and ASPR increased significantly (22.1 % and 24.8 %, respectively), while ASDALYsR and ASDR declined. High-income regions exhibited the greatest disease burden, notably High-income North America and Western Europe. Marked sex-based differences existed, with males showing higher burden compared to females. Projections indicate that by 2041, the absolute number of cases will rise by 72.1 %.

Conclusions

The global burden of NRCAVD in older adults is substantial and varies by age, gender, socio-demographic index, and region. Despite declining age-standardized rates, the absolute burden of NRCAVD will increase, highlighting the need for early screening and improved treatment access.

Keywords: Non-rheumatic calcific aortic valve disease, Global burden of disease, Aging

Graphical abstract

Image 1

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List of abbreviations:

AAPC =

Average annual percent change

AVR =

Aortic valve replacement

NRCAVD =

Non-rheumatic calcific aortic valve disease

ASDALYsR =

Age-standardized disability-adjusted life years rate

ASDR =

Age-standardized death rate

ASIR =

Age-standardized incidence rate

ASPR =

Age-standardized prevalence rate

CI =

Confidence interval

DALYs =

Disability-adjusted life years

GBD =

Global Burden Disease

SDI =

Socio-demographic index

TAVR =

Transcatheter aortic valve replacement

1. Background

Non-rheumatic calcific aortic valve disease (NRCAVD) is a progressive cardiovascular disorder predominantly affecting older adults, characterized by degenerative calcification and fibrosis of the aortic valve, leading ultimately to significant aortic stenosis and impaired cardiac function [1,2]. In 2022, the number of prevalent NRCAVD cases was estimated at 13.6 million [3]. NRCAVD is a major contributor to global cardiovascular morbidity and mortality, particularly in the aging population [4,5], and it imposes substantial social and economic costs. Unlike rheumatic heart disease, which arises primarily from prior Streptococcus infections, NRCAVD results from a complex interplay of age-related degenerative processes, metabolic dysregulation, chronic inflammation, and lipoprotein deposition [6,7]. The progression of the disease is typically insidious, extending over decades, often remaining clinically silent until severe valvular dysfunction necessitates surgical or transcatheter aortic valve replacement (AVR) [1,8].

With global increases in life expectancy and population aging, the burden of NRCAVD is escalating, presenting significant challenges to public health systems worldwide [9,10]. Over the past three decades, enhanced diagnostic capabilities and demographic shifts have contributed to substantial increases in NRCAVD prevalence and incidence, particularly in high-income regions [11,12]. Improved cardiovascular imaging technologies, such as echocardiography and computed tomography, have facilitated earlier detection and accurate diagnosis, revealing a previously under-recognized burden [13]. Simultaneously, low- and middle-income countries are experiencing growing NRCAVD prevalence due to epidemiological transitions characterized by shifting risk factor profiles, although these regions often lack adequate diagnostic and interventional resources [4,10].

Despite significant advancements in therapeutic interventions, particularly transcatheter aortic valve replacement (TAVR) and surgical AVR, NRCAVD continues to impose considerable burden in terms of disability-adjusted life years (DALYs) and premature mortality [1,12]. However, comprehensive global epidemiological data detailing the current burden of NRCAVD among adults aged ≥60 years and projecting future trends remains limited. Given that older adults represent the predominant demographic affected by NRCAVD, accurately quantifying this group's current and future disease burden is essential for effective healthcare planning and resource allocation.

Utilizing the Global Burden of Disease (GBD) Study 2021, this study aims to systematically analyze the global, regional, and national trends of NRCAVD among adults aged ≥60 years from 1990 to 2021, focusing on age-standardized incidence (ASIR), prevalence (ASPR), DALYs (ASDALYsR), and death rates (ASDR). Furthermore, leveraging the Nordpred age-period-cohort model, this study projects NRCAVD burden trends up to 2041, providing essential insights to inform global cardiovascular health strategies and public health policies.

2. Methods

2.1. Overview of the data sources

The GBD 2021 systematically estimated the incidence, prevalence, DALYs and death for 371 diseases and injuries across 204 countries and territories from 1990 to 2021, stratified by age, sex, and location. Data were obtained from various sources, including censuses, household surveys, civil registrations, vital statistics, disease registries, and other methods. Mortality estimates were generated using the Cause of Death Ensemble modeling approach, while DALYs were computed using DisMod-MR 2.1, a Bayesian meta-regression analytical tool. To facilitate comparative analysis, countries and territories were grouped into 21 super-regions based on similarities in epidemiological profiles and geographic proximity. Additionally, the Socio-demographic Index (SDI) was applied to classify countries according to their level of socio-economic development.

2.2. Estimation of NRCAVD disease burden in older adults aged ≥60 years

We obtained data on the incidence, prevalence, DALYs, and death rates of NRCAVD according to region from the 2021 GBD study. Relevant data were retrieved from the following website (https://vizhub.healthdat.org/gbd-results/).

2.3. Predicting incidence, prevalence, DALYs, and death of NRCAVD in older adults aged ≥60 years

The Nordpred prediction model, based on the age-period-cohort method, effectively estimates future trends in disease incidence, prevalence, DALYs, and death. It accounts for demographic factors such as population aging, disease trends over time, and generational influences. In this study, the Nordpred model was used to project NRCAVD incidence, prevalence, DALYs, and deaths from 2022 to 2041. The analyses were conducted using the Nordpred package in R software [14], which dynamically incorporates variations in population demographics and disease incidence rates.

2.4. Statistical analysis

Data from the GBD 2021 database (https://vizhub.healthdata.org/gbdresults/) were used to calculate ASIR, ASPR, ASDALYsR, and ASDR per 100,000 population, along with 95 % confidence intervals (CIs), from 1990 to 2021. Rates were standardized using the GBD 2021 world population via the 'epitools' package in R (version 4.3.2) [15,16]. Temporal trends were quantified by average annual percent change (AAPC) with Monte Carlo permutation tests to assess statistical significance (P < 0.05). NRCAVD burden across 204 countries was explored, and correlations between age-standardized rates and the SDI were evaluated using Spearman's method. Future trends were projected with the “Nordpred” package in R (version 4.3.2). Statistical significance was set at a two-sided P < 0.05.

3. Results

3.1. Global NRCAVD burden among older adults aged ≥60 years in 2021

In 2021, the global number of patients with NRCAVD in older adults aged ≥60 years reached 11.78 million, with 0.84 million new cases reported. The ASIR and ASPR were 77.3 per 100,000 population and 1122.7 per 100,000 population, respectively. In the same year, NRCAVD was responsible for 132,764 deaths worldwide, with an ASDR of 13.7 per 100,000 population. Additionally, the ASDALYsR due to NRCAVD was estimated at 182 per 100,000 population (Supplementary File 1 Tables: Table S1; Fig. 1).

Fig. 1.

Fig. 1

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Global burden of NRCAVD in older adults aged ≥60 years from 1990 to 2021. A Age-standardized rate of NRCAVD burden in older adults aged ≥60 years from 1990 to 2021. B Age-standardized rate of NRCAVD burden in older men aged ≥60 years from 1990 to 2021. C Age-standardized rate of NRCAVD burden in older women aged ≥60 years from 1990 to 2021. NRCAVD: Non-rheumatic calcific aortic valve disease; ASR: Age-standardized rate.

Further analysis revealed sex-based disparities in the global burden of NRCAVD among individuals aged 60 years and older in 2021. Males exhibited a higher ASIR (86.4 per 100,000) than females (68.9 per 100,000). Similarly, the ASPR for males was also higher (1352.6 per 100,000 vs. 935.5 per 100,000), as was the ASDALYsR (196.1 per 100,000 for males vs. 168.1 per 100,000 for females). The ASDR was also slightly higher in males (13.9 per 100,000) compared to females (13.2 per 100,000) (Supplementary File 1 Tables: Table S1; Fig. 1).

3.2. NRCAVD burden among older adults aged ≥60 years across locations in 2021

In 2021, the relationship between the ASIR, ASPR, ASDALYsR, and ASDR of NRCAVD with the SDI followed an ascending trend. The highest burden of NRCAVD was observed in high-SDI regions (Supplementary File 1 Tables: Table S1; Supplementary File 2 Figures: Fig. S1–S3; Fig. 2).

Fig. 2.

Fig. 2

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Age-standardized rate of NRCAVD burden by 5 SDI regions from 1990 to 2021. A Age-standardized rate of NRCAVD burden in older adults aged ≥60 years from 1990 to 2021. B Age-standardized rate of NRCAVD burden in older men aged ≥60 years from 1990 to 2021. C Age-standardized rate of NRCAVD burden in older women aged ≥60 years from 1990 to 2021. NRCAVD: Non-rheumatic calcific aortic valve disease; SDI: Socio-demographic index; ASR: Age-standardized rate.

In high-SDI regions, the ASIR, ASPR, ASDALYsR, and ASDR of NRCAVD were 196.2 per 100,000 population, 2447.3 per 100,000 population, 345.5 per 100,000 population, and 26.1 per 100,000 population, respectively. Among males in high-SDI regions, these rates were notably higher, with an ASIR of 223.5 per 100,000 population, an ASPR of 3002.9 per 100,000 population, an ASDALYsR of 388.7 per 100,000 population, and an ASDR of 27.7 per 100,000 population. In contrast, among females in high-SDI regions, the corresponding values were 171.3 per 100,000 (ASIR), 1989.9 per 100,000 (ASPR), 307.3 per 100,000 (ASDALYsR), and 24.4 per 100,000 (ASDR) (Supplementary File 1 Tables: Table S1; Fig. 2).

At the regional level, High-Income North America reported the highest ASIR of 242.2 per 100,000 population, while Western Europe exhibited the highest ASPR at 3006 per 100,000, ASDALYsR at 432.5 per 100,000, and ASDR at 32.2 per 100,000. Regarding sex-specific differences, High-Income North America recorded the highest ASIR of 294.8 per 100,000 among males. In contrast, Western Europe reported the highest ASPR (3838.5 per 100,000), ASDALYsR (498.7 per 100,000), and ASDR (35.1 per 100,000) for male NRCAVD. Similarly, Western Europe exhibited the highest ASIR (203.4 per 100,000), ASPR (2307.2 per 100,000), ASDALYsR (375.5 per 100,000), and ASDR (29.6 per 100,000) for female NRCAVD (Supplementary File 1 Tables: Table S1; Supplementary File 2 Figures: Fig. S4).

Country-specific analyses revealed that Slovenia had the highest burden of NRCAVD across multiple metrics. Slovenia recorded the highest ASIR at 514.6 per 100,000, highest ASPR at 7132.2 per 100,000, highest ASDALYsR at 1073.9 per 100,000, and highest ASDR at 77.9 per 100,000. Among males, Slovenia exhibited the highest ASIR (540.5 per 100,000), ASPR (8069.5 per 100,000), ASDALYsR (1147.6 per 100,000), and ASDR (79.2 per 100,000). Similarly, among females, Slovenia recorded the highest ASIR (490.3 per 100,000), ASPR (6367.8 per 100,000), and ASDR (75 per 100,000). However, the highest ASDALYsR for female NRCAVD was observed in the United Arab Emirates, at 1066.3 per 100,000 (Supplementary File 1 Tables: Table S2; Fig. 3; Supplementary File 2 Figures: Fig. S5).

Fig. 3.

Fig. 3

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Age-standardized burden of NRCAVD across 204 countries/territories in older adults aged ≥60 years in 2021. NRCAVD: Non-rheumatic calcific aortic valve disease; DALYs: Disability-adjusted life years; ASIR: Age-standardized incidence rate; ASPR: Age-standardized prevalence rate; ASDALYsR: Age-standardized DALYs rate; ASDR: Age-standardized death rate.

3.3. Global temporal trends in NRCAVD burden among older adults aged ≥60 years (1990–2021)

Between 1990 and 2021, the global ASIR and ASPR of NRCAVD increased by 22.1 % (from 63.3 to 77.3 per 100,000 population) and 24.8 % (from 899.9 to 1122.7 per 100,000 population), respectively. However, a recent declining trend in both ASIR and ASPR has been observed over the past seven years. In contrast, the ASDALYsR and the ASDR declined by 11.4 % (from 205.4 to 182 per 100,000 population) and 3.5 % (from 14.2 to 13.7 per 100,000 population), respectively, with a particularly noticeable decline starting in 2015 (Supplementary File 1 Tables: Table S1; Fig. 1).

Among males, the global ASIR and ASPR of NRCAVD increased by 25.9 % (from 68.6 to 86.4 per 100,000) and 26.8 % (from 1066.5 to 1352.6 per 100,000), respectively, between 1990 and 2021. In contrast, the ASDALYsR declined by 9.5 % (from 216.6 to 196.1 per 100,000 population), while the ASDR remained unchanged at 13.9 per 100,000 population. Among females, the global ASIR and ASPR of NRCAVD increased by 18.6 % (from 58.1 to 68.9 per 100,000) and 20.8 % (from 774.5 to 935.5 per 100,000), respectively, over the same period. Meanwhile, the ASDALYsR and ASDR of female NRCAVD declined by 12.7 % (from 192.6 to 168.1 per 100,000) and 5 % (from 13.9 to 13.2 per 100,000), respectively (Supplementary File 1 Tables: Table S1; Fig. 1).

3.4. Regional temporal trends in NRCAVD burden among older adults aged ≥60 years (1990–2021)

Across the five SDI regions, both the ASIR and ASPR of NRCAVD demonstrated an increasing trend from 1990 to 2021. The highest increase in ASIR was observed in middle-SDI regions, with an AAPC of 1.53 (95 % CI: 1.48–1.59), while the largest increase in ASPR was also reported in middle-SDI regions, with an AAPC of 1.62 (95 % CI: 1.56–1.68). The ASDALYsR of NRCAVD increased across all SDI regions except for high-SDI regions during the same period. The highest increase in ASDALYsR was recorded in low-middle SDI regions, with an AAPC of 0.77 (95 % CI: 0.47–1.08). Similarly, the ASDR increased across all SDI regions except for high- and middle-SDI regions, with the highest increase in ASDR observed in high-middle SDI regions (AAPC: 1.09 [95 % CI: 0.83–1.37]). Sex-specific trends revealed that both the ASIR and ASPR of male NRCAVD increased from 1990 to 2021 across all five SDI regions. The highest increase in ASIR was reported in middle-SDI regions (AAPC: 1.49 [95 % CI: 1.44–1.54]), with the most substantial increase in ASPR also occurring in middle-SDI regions (AAPC: 1.54 [95 % CI: 1.49–1.59]). Similarly, among females, the ASIR and ASPR of NRCAVD exhibited an upward trend, with the highest increase in ASIR observed in middle-SDI regions (AAPC: 1.59 [95 % CI: 1.4–1.77]) and the largest increase in ASPR occurring in the same regions (AAPC: 1.72 [95 % CI: 1.54–1.91]) (Supplementary File 1 Tables: Table S1).

Regionally, Central Europe exhibited the most rapid increase in ASIR, with an AAPC of 2.47 (95 % CI: 2.33–2.62), and the highest growth in the ASPR, with an AAPC of 2.29 (95 % CI: 2.17–2.43). Eastern Europe demonstrated the fastest growth in the ASDALYsR, with an AAPC of 3.92 (95 % CI: 3.43–4.40), while Central Asia recorded the most pronounced increase in the ASDR, with an AAPC of 5.05 (95 % CI: 3.13–7.01). Among males, Central Europe exhibited the most rapid increase in ASIR (AAPC: 2.35 [95 % CI: 2.21–2.49]) and the highest increase in ASPR (AAPC: 2.18 [95 % CI: 2.02–2.34]). Eastern Europe demonstrated the fastest growth in ASDALYsR (AAPC: 3.62 [95 % CI: 2.79–4.46]) and ASDR (AAPC: 4.97 [95 % CI: 3.68–6.28]). Similarly, among females, Central Europe exhibited the most rapid increase in ASIR (AAPC: 2.52 [95 % CI: 2.33–2.71]) and ASPR (AAPC: 2.33 [95 % CI: 2.17–2.49]). Additionally, Central Europe showed the fastest growth in ASDALYsR (AAPC: 3.95 [95 % CI: 3.52–4.39]), while Central Asia recorded the most significant increase in ASDR (AAPC: 5.16 [95 % CI: 3.12–7.24]) (Supplementary File 1 Tables: Table S1).

The temporal trends of NRCAVD burden by country and territory are presented in Supplementary File 1 Tables: Table S3. Croatia exhibited the most rapid increase in the ASIR of NRCAVD, with an AAPC of 4.18 (95 % CI: 3.95–4.42), and the highest growth in the ASPR, with an AAPC of 3.9 (95 % CI: 3.77–4.04).

Further age-specific analyses of trends both globally and across sub-SDI regions revealed that the DALYs and death rates for NRCAVD increased with age. (Supplementary File 2 Figures: Figures S6–S9).

3.5. Global prediction of NRCAVD burden in older adults aged ≥60 years from 2022 to 2041

The ASIR of NRCAVD is projected to remain stable over the next two decades. In contrast, the ASPR is expected to decline, decreasing from 1123.8 per 100,000 in 2022 to 1078.2 per 100,000 in 2041. Additionally, both the ASDALYsR and ASDR are anticipated to decrease globally between 2022 and 2041, with projected values of 162.1 and 11.8 per 100,000, respectively, by 2041. The ASIR of NRCAVD among males is expected to increase by 2.2 % from 2022 to 2041. However, the ASPR, ASDALYsR, and ASDR for males are projected to decline over the next two decades, decreasing by 4 %, 9.1 %, and 12.1 %, respectively. In contrast, among females, the ASIR, ASPR, ASDALYsR, and ASDR are all projected to decline over the same period, with respective reductions of 2.6 %, 4.6 %, 12.5 %, and 14.8 % (Fig. 4).

Fig. 4.

Fig. 4

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Predicted trends of global NRCAVD burden in older adults aged ≥60 years over 20 years (2022–2041). A Projected number of cases and ASR trends in older adults aged ≥60 years. B Projected number of cases and ASR trends in older men aged ≥60 years. C Projected number of cases and ASR trends in older women aged ≥60 years. NRCAVD: Non-rheumatic calcific aortic valve disease; ASR: Age-standardized rate.

Despite these trends in age-standardized rates, the absolute number of cases is expected to increase significantly over the next 20 years. The total number of NRCAVD incidence, prevalence, DALYs, and deaths is projected to rise by 65.5 %, 72.1 %, 73.3 %, and 79 %, respectively. Among males, these numbers are expected to increase by 67 %, 71.6 %, 76.2 %, and 84.9 %, respectively. Similarly, among females, incidence, prevalence, DALYs, and deaths are projected to increase by 63.9 %, 72.8 %, 70.8 %, and 74.9 %, respectively (Fig. 4).

4. Discussion

Currently, comprehensive analyses of the global burden of NRCAVD specifically among older adults remain limited. Age is a critical determinant influencing the structural and functional integrity of the cardiovascular system [17], rendering older populations particularly susceptible to cardiovascular diseases. According to cardiovascular disease statistics 2021 of European society of cardiology, calcific aortic valve disease has emerged as one of the most prevalent forms of valvular heart disease in Europe, with significantly higher incidence rates observed beyond the age of 65 years [18]. So, in this study, we used GBD 2021 data to analyze NRCAVD in older adults.

This study provides the first systematic, comprehensive assessment of the global burden, temporal trends, and future projections of NRCAVD among adults aged ≥60 years, based on robust epidemiological data from the Global Burden of Disease Study 2021. Our analysis underscores that NRCAVD among adults aged ≥60 years represents a significant and growing public health challenge worldwide. Between 1990 and 2021, the global ASIR and ASPR of NRCAVD increased by 22.1 % and 24.8 %, respectively. Conversely, declines observed in ASDR and ASDALYsR likely reflect advancements in clinical management, surgical techniques, and increased accessibility to TAVR, particularly in high-income regions.

Despite these promising trends, our projections reveal that the absolute burden of NRCAVD will continue to rise substantially, increasing by an estimated 72.1 % by 2041, predominantly driven by global population aging. The rapid increase in life expectancy and significant demographic transitions toward an older population structure worldwide are the primary contributors to this growing burden. As NRCAVD primarily affects older adults, the expansion of aging populations directly correlates with a heightened absolute number of individuals susceptible to developing the disease [12,19]. Although advancements in medical management and interventions like TAVR are expected to improve clinical outcomes and survival rates [20], the sheer growth in the older demographic will inevitably amplify the disease's societal and healthcare impact. To address these demographic-driven challenges, global health strategies must prioritize early screening programs, proactive management of modifiable risk factors, and enhancement of healthcare infrastructure to accommodate the increasing number of older adults requiring care for NRCAVD.

Emerging evidence suggests that in elderly patients with NRCAVD, systemic factors like atrial arrhythmia burden and nutritional status significantly impact long-term outcomes. Studies in octogenarians with pacemakers show that both atrial high-rate episodes and malnutrition independently increase the risk of atrial fibrillation, heart failure, and mortality [21,22]. The biological pathways linking these factors—chronic inflammation, oxidative stress, metabolic impairment, and structural remodeling—closely overlap with those driving NRCAVD progression. Malnutrition may exacerbate inflammation and impair repair, while atrial remodeling reflects broader myocardial vulnerability. Thus, NRCAVD should be viewed not merely as localized valvular degeneration, but as part of a spectrum of age-related cardiovascular decline. This broader perspective helps explain regional and sex-based variations and underscores the value of comprehensive geriatric assessment—including nutrition and arrhythmia monitoring—in managing at-risk older adults.

From 1990 to 2021, both males and females exhibited similar trends in ASIR, ASPR, ASDALYsR, and ASDR for NRCAVD. However, our findings highlight a significant sex-based disparity in 2021, with males bearing a greater disease burden than females globally. This disparity may partly be explained by biological factors, including the protective effects of estrogen, which reduce the risk of calcific valve disease in premenopausal females compared to males of similar age [23]. Although females typically have higher average blood pressure and hypertension prevalence after the age of 60 years [24], studies indicate they also possess higher rates of hypertension awareness, treatment, and control compared to males, both in high-income and low- or middle-income countries [25]. Furthermore, previous studies have shown that males tend to develop severe aortic stenosis approximately 10 years earlier than females [26], which aligns with observations from ischemic heart disease research in Western populations, where females develop disease 7–10 years later than their male counterparts [27]. These factors likely contribute to the higher age-standardized disease burden observed in males. Additionally, the observed sex-based differences may reflect underlying gender disparities in healthcare access, diagnosis, and clinical management of NRCAVD. Our findings emphasize the necessity for further research into sex-specific diagnostic protocols, treatment strategies, and public health interventions aimed at enhancing awareness, early detection, and equitable care, particularly among female populations.

Our results showed that the burden of NRCAVD was primarily concentrated in high-SDI regions. We found that the global age-standardized rates of NRCAVD in high-SDI regions, particularly in High-income North America and Western Europe, were significantly higher than those in other regions. The observed disparities in NRCAVD burden across different SDI levels, regions, and countries may be attributed to various factors, including economic development, the availability and distribution of medical resources, healthcare policies, demographic aging, public awareness, education levels, dietary and lifestyle patterns, genetic predisposition, and environmental conditions. Previous research has linked poor housing conditions [28], transportation noise pollution [29] and air pollution [30] to increased cardiovascular disease risks, which could partially explain regional variations in NRCAVD. Additionally, greater healthcare accessibility [31] and advanced diagnostic capabilities in developed countries likely facilitate more frequent identification of NRCAVD cases, particularly among asymptomatic individuals. Moreover, higher NRCAVD prevalence in high-SDI regions might also be partly explained by reduced competing mortality from other diseases that typically cause earlier death in less-developed regions [32]. Finally, given that NRCAVD primarily affects older adults, prolonged life expectancy [11] in high-SDI areas could contribute significantly to the rising incidence and prevalence observed in these regions.

Conversely, the most rapid increases in ASIR and ASPR were observed in middle-SDI regions, the greatest rise in ASDALYsR occurred in low-middle SDI regions, and the highest increase in ASDR was noted in high-middle SDI regions. These results likely reflect substantial differences in healthcare infrastructure, diagnostic capacity, and accessibility to advanced treatments such as TAVR across non-high SDI regions. Insufficient medical resources and delayed clinical intervention in these areas may contribute to widespread underdiagnosis and inadequate disease management [33,34], consequently driving rapid growth in NRCAVD burden. Addressing these inequities through strengthening healthcare infrastructure, expanding access to advanced cardiovascular therapies, and enhancing early screening and timely intervention strategies could significantly mitigate the future burden of NRCAVD in these vulnerable regions.

Death due to NRCAVD has been significantly influenced by advancements in TAVR over the past decade [1,20,35]. A recent study using data from the US National Center for Health Statistics indicated that the age-adjusted mortality rate from aortic stenosis rose until 2013, after which it began to decline [20]. Our study similarly demonstrated a global decrease in ASDR from NRCAVD starting in 2015. This decline coincides with a rapid increase in the number of TAVR procedures, suggesting that the expanded use of TAVR therapy might have contributed to improved survival outcomes for NRCAVD patients. Recent evidence from Japan also supports the effectiveness of TAVR for treating aortic stenosis, even in extremely elderly patients such as nonagenarians [36].

5. Limitations

Several limitations of this study should be acknowledged. First, data availability varies considerably across countries, with low-SDI countries likely having less accurate estimates of NRCAVD burden due to incomplete or unavailable data stemming from underdeveloped public health infrastructure. Second, the widespread adoption of advanced diagnostic imaging modalities such as echocardiography and computed tomography from 1990 to 2021 may have led to increased identification of asymptomatic NRCAVD in recent years compared to earlier periods, potentially inflating the apparent incidence and prevalence trends. Third, the GBD 2021 database does not differentiate between symptomatic and asymptomatic NRCAVD or clearly distinguish between specific subtypes, such as aortic stenosis and aortic regurgitation. Future epidemiological studies should focus on the detailed subtyping of NRCAVD to accurately delineate its disease burden. These limitations necessitate cautious interpretation of our findings and underscore the need to enhance data quality and standardization in future global health research on NRCAVD.

6. Conclusions

There was a substantial global burden of NRCAVD among older adults in 2021, with significant variations observed by age, gender, SDI, and geographical region. The burden was predominantly concentrated in high-SDI regions, and notably heavier among males. Such gender disparities may reflect underlying inequities in clinical services and disease management related to NRCAVD. Future research should prioritize identifying cost-effective preventive strategies and developing innovative healthcare delivery models to reduce the global burden of NRCAVD effectively.

CRediT authorship contribution statement

Jie Tan: Writing – original draft, Visualization, Methodology, Investigation. Xiaoqing Fu: Writing – original draft, Visualization, Supervision, Formal analysis, Data curation. Xiaoqi Li: Writing – original draft, Visualization, Formal analysis, Data curation. Xiaorui Zhao: Formal analysis, Data curation, Conceptualization. Wenqi Huang: Writing – review & editing, Conceptualization. Jing Huang: Writing – review & editing, Project administration, Methodology. Li Xu: Writing – review & editing, Supervision, Resources, Project administration, Investigation, Conceptualization.

Ethics approval and consent to participate

For the GBD is publicly available and no identifiable information was included in the analyses, the ‘Ethical approval and consent to participate’ was not applicable.

Consent for publication

Not applicable.

Funding

This work was supported by the National Natural Science Foundation of China (No. 82170445), and the Medical technology innovation “Unveiling Command Project” of the Second Affiliated Hospital of Chongqing Medical University (No. 2023ⅡT094).

Declaration of competing interest

The authors declare that they have no conflict of interest.

Acknowledgements

We are grateful to the Institute of Health Metrology and Evaluation for sharing valuable GBD data.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijcrp.2025.200565.

Contributor Information

Jing Huang, Email: huangjingcqmuc@163.com.

Li Xu, Email: 304182@hospital.cqmu.edu.cn.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Multimedia component 1
mmc1.docx (4.7MB, docx)
Multimedia component 2
mmc2.docx (350KB, docx)

Data availability

Relevant data can be retrieved through the available website (https://vizhub.healthdata.org/gbd-results/).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Multimedia component 1
mmc1.docx (4.7MB, docx)
Multimedia component 2
mmc2.docx (350KB, docx)

Data Availability Statement

Relevant data can be retrieved through the available website (https://vizhub.healthdata.org/gbd-results/).

Articles from International Journal of Cardiology. Cardiovascular Risk and Prevention are provided here courtesy of Elsevier

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