The evolving burden of ischemic heart disease in China, 1990-2023: Three decades of trends, risk factors, and future challenges

Highlights

• •From 1990 to 2023, the absolute number of ischemic heart disease cases and deaths in China nearly tripled, although age-standardized rates declined.
• •Population aging was the dominant driver, accounting for over 120 % of the increase in disability-adjusted life years (DALYs), while epidemiological changes mitigated mortality and DALY rates.
• •High systolic blood pressure remained the leading risk factor, responsible for nearly 20 million DALYs, followed by lead exposure and high LDL cholesterol.
• •Significant sex and age disparities were observed, with a higher burden in older women.
• •Projections to 2035 indicate an overall decline in total burden but a continued rise in cases among adults aged 60 and older.

Abstrct

Background

Ischemic heart disease represent a critical and growing public health challenge in China, against a backdrop of rapid demographic and epidemiological transitions.

Objective

This comprehensive analysis aims to analyze the evolving burden, risk factors, and demographic drivers of ischemic heart disease in China from 1990 to 2023 to inform targeted policy and clinical interventions.

Methods

Using data from the Global Burden of Disease 2023 study, we systematically examined ischemic heart disease prevalence, mortality, disability-adjusted life years (DALYs), and associated risk factors in China. A Bayesian Age-Period-Cohort model was applied for future predictions.

Results

From 1990 to 2023, the absolute number of ischemic heart disease prevalence cases in China increased by 174.95%, deaths by 173.76%, and DALYs by 100.02%. However, age-standardized mortality and DALY rates declined. Significant disparities were observed: males generally bore a higher burden, though females had higher prevalence after age 75 and higher mortality after 80. Decomposition analysis identified population aging as the primary driver, accounting for 124.46% of the increase in DALYs, while epidemiological changes mitigated mortality and DALY rates. High systolic blood pressure was the leading risk factor, followed by lead exposure and high LDL cholesterol. Smoking and dietary risks also contributed substantially. Projections to 2035 suggest an overall decline in total burden but a continued rise in cases among adults aged 60 and older.

Conclusion

The findings highlight the urgent need for enhanced, equitable prevention strategies focusing on blood pressure control, environmental health, tobacco regulation, and dietary interventions, alongside integrated, patient-centered care models tailored to the aging population and gender-specific vulnerabilities of ischemic heart disease in China.

1. Introduction

Cardiovascular diseases stand as a preeminent challenge to global public health, accounting for approximately one-third of all deaths worldwide and representing a significant barrier to sustainable human development [1]. Within the spectrum of cardiovascular diseases, ischemic heart disease is the leading cause of mortality and disability globally [2,3]. The total number of ischemic heart disease deaths globally increased substantially over the past three decades, rising from 5.37 million in 1990 to 8.99 million in 2021, representing a 67.5 % increase [4]. The epidemiological trajectory of ischemic heart disease exhibits marked disparity between nations; while mortality rates have declined substantially in many high-income countries over recent decades, a concerning rise has been observed in numerous high-middle-income countries [[4], [5], [6], [7]].

China, as the world's most populous high-middle-income countries, has undergone rapid epidemiological and demographic transitions alongside its remarkable economic growth. This has been accompanied by a swift escalation in the prevalence and mortality of non-communicable diseases, with ischemic heart disease emerging as a paramount threat [6]. By 2013, ischemic heart disease had become the second leading cause of death in China, surpassed only by stroke [7]. This escalating burden prompted a robust policy response, including the launch of the national "Healthy China 2030″ initiative, which aligns with the United Nations' Sustainable Development Goal target 3.4.1 to reduce premature mortality from major non-communicable diseases [[8], [9], [10]].

The aetiology of ischemic heart disease is multifactorial, with a substantial proportion of its burden attributable to modifiable risks. Established factors such as hypertension, high LDL cholesterol, dietary high sodium intake, smoking, and ambient air pollution have been consistently implicated [11,12]. Research into these factors is therefore critical for developing effective, targeted prevention strategies. However, a comprehensive understanding of the spatiotemporal evolution of ischemic heart disease burden, its key drivers, and its future trajectory within China's diverse population has been hampered by a lack of systematic, comparable data across subnational regions and over extended time periods.

The Global Burden of Disease (GBD) studies provide a valuable framework for addressing this gap, producing standardized and comparable estimates of health loss due to fatal and non-fatal disease outcomes [13]. The GBD 2023 study provides an updated, standardized, and comparable framework to analyze and integrates global disease and health data, making it a valuable tool for studying the global, regional, and national burden of GBDs across different age groups, allowing for a detailed analysis of trends over the past three decades [14]. Leveraging this robust data source, this study aims to systematically analyze the trends in ischemic heart disease mortality and disability-adjusted life years (DALYs) in China from 1990 to 2023. We further seek to quantify the burden attributable to major metabolic, environmental, and behavioural risk factors, and to project the future burden through 2035. The findings are intended to inform evidence-based health policy and resource allocation, guiding the ongoing efforts to curb the ischemic heart disease epidemic and achieve the goals of "Healthy China 2030."

2. Methods

2.1. Study population and data collection

In our analysis of the GBD Study 2023, which published by the Institute for Health Metrics and Evaluation, we accessed repeated cross sectional data from the Global Health Data Exchange, encompassing the burden of 375 diseases and injuries, risk-attributable burden of 88 risk factors, and healthy life expectancy in 204 countries and territories, including 660 subnational locations from 1990 to 2023 (https://vizhub.healthdata.org/gbd-results^/) [15,16]. Prevalence, death, and DALYs (number and rate) with 95 % uncertainty intervals (UIs) for ischemic heart disease were sourced from GBD 2023. All estimates from the GBD study are presented with 95 % UIs, which represent a range of values that reflects the total computational and data-related uncertainty, encompassing input data variability, measurement error corrections, and residual non-sampling error estimates, as per the GBD methodology. We obtained the age-standardized prevalence rates (ASPR), age-standardized mortality rates (ASMR), and age-standardized DALY rates (ASDR) for ischemic heart disease directly from the GBD 2023 results, which are calculated based on the GBD World Standard Population. The methodologies for estimation and standardization are described in the primary GBD capstone papers [15,17,18]. According to the GBD world population, an age-standardized rate (ASR) analysis was recorded per 100,000 population [19]. The loss of one year of healthy life is equivalent to a DALYs, and DALYs were equal to the sum of years lived with disability and years of life lost [20]. ASR corresponding to the number of ischemic heart disease cases and deaths were screened, and the average annual percent change (AAPC) was calculated to assess long‐term trends in the ASR of ischemic heart disease burden. All risk factors were defined in eTable 1. We have removed any mention of estimates for the population under 15 years of age, as the GBD 2023 study does not provide measure data for ischemic heart disease in this age group due to the extremely rare occurrence of the disease, making estimates unfeasible.

2.2. Statistical analysis

A descriptive analysis was performed to characterize the burden of ischemic heart disease in China. The Bayesian age-period-cohort model (BAPC) integrated nested Laplace approximations (INLA) to predict the ischemic heart disease burden over the next 30 years. To ensure smoothing, BAPC models assume independent mean-zero normal distributions on the second differences of all effects [21]. The detailed BAPC model equations, technical descriptions and decomposition analysis are in the Supplementary Online Content [22]. The solid lines in the figures are fitted using the Locally Estimated Scatterplot Smoothing method. In our study, the R software package (version 4.2.3) and JD_GBDR (V2.27, Jingding Medical Technology Co., Ltd.) was used for the drawing of the figures. P-values <0.05 were considered to be statistically significant. The detail methodology employed in this study is also described in our related publications [19].

Data availability

All data used are available upon reasonable request to the corresponding authors.

Ethics

The study was exempted from the ethics committee review as the publicly available data did not contain any confidential patient information. Each step used to analyse the GBD database in the current study followed the guideline of cross-sectional study described in the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) [23].

3. Results

3.1. Prevalence analysis and trend of ischemic heart disease

The prevalence cases of ischemic heart disease in China increased from 24,257,684 (UI: 20,534,740,29,620,523) cases in 1990 to 66,695,391 (95 % UI: 55,561,815,79,427,075) in 2023. From 1990 to 2023, marking a 174.95 % (95 % UI: 152.08 %,198.08 %) rise, while the ASPR also grew from 2813.71 (95 % UI: 2366.12,3383.23) to 3019.97 (95 % UI: 2553.14,3605.54) per 100,000 during the same period (Table 1 and Fig. 1A, B). Significant age and sex disparities were observed: no cases were reported under age 15, but prevalence rose steadily from age 15 onward, with males consistently exhibiting higher rates than females across most age groups, except among those aged 75+ years, where females showed slightly higher rates in 2023 (Fig. 2A). Sex-specific prevalence cases and ASPR trends revealed persistently higher values in males, though a decline occurred post-2000, contrasted by a steady increase among females after 2011. The AAPC was 3.23 % (95 % CI: 3.10 %, 3.36 %) (p < 0.001) from 1990 to 2023, with segmented phases showing accelerated growth, a brief decline, and subsequent resurgence, reflecting influences from aging, lifestyle changes, risk factors, and possibly public health interventions (Fig. 3A). These findings underscore the need for targeted prevention and management strategies, particularly for older adults and males.

Table 1.

Prevalence, death and DALYs of ischemic heart disease in China between 1990 and 2023.

Measure	1990		2023		1990–2023
	Number (95 % UI)	ASR per 100,000 (95 %UI)	Number (95 %UI)	ASR per 100,000 (95 %UI)	Cases change ( %)	AAPC (95 %CI)
Prevalence
Both	24,257,684 (20,534,740,29,620,523)	2813.71 (2366.12,3383.23)	66,695,391 (55,561,815,79,427,075)	3019.97 (2553.14,3605.54)	174.95 (152.08,198.08)	3.23 (3.10,3.36)
Female	10,417,298 (8851,514,12,731,151)	2398.50 (2009.33,2868.96)	30,245,766 (24,941,783,36,415,602)	2581.73 (2165.42,3112.80)	190.34 (163.09,218.66)	3.36 (3.31,3.41)
Male	13,840,387 (11,680,569,16,921,839)	3259.03 (2735.90,3931.31)	36,449,625 (30,662,384,43,704,683)	3448.83 (2923.41,4101.17)	163.36 (140.62,183.51)	3.32 (3.07,3.56)
Death
Both	727,481 (589,332,862,081)	112.32 (91.23,133.63)	1991,576 (1684,998,2248,367)	93.19 (78.67,105.49)	173.76 (121.56,251.49)	2.96 (2.61,3.31)
Female	343,932 (245,240,437,348)	99.98 (73.15,125.71)	919,921 (712,140,1109,518)	77.56 (60.14,93.66)	167.47 (86.23,279.68)	2.93 (2.47,3.39)
Male	383,550 (270,480,501,950)	126.93 (91.09,161.63)	1071,655 (904,681,1248,697)	110.22 (93.16,128.95)	179.40 (108.43,304.50)	3.11 (2.75,3.46)
DALYs
Both	18,510,283 (14,827,506,22,256,069)	2281.61 (1870.12,2721.98)	37,023,944 (32,947,704,40,787,339)	1694.23 (1496.51,1865.45)	100.02 (63.25,157.95)	1.99 (1.67,2.30)
Female	7983,478 (5621,668,10,667,267)	1939.87 (1400.50,2526.81)	14,874,724 (12,051,576,17,618,434)	1258.39 (1016.08,1490.07)	86.32 (36.47,164.81)	2.20 (1.92,2.48)
Male	10,526,804 (7366,953,13,758,675)	2644.42 (1879.13,3417.65)	22,149,220 (19,220,878,25,074,745)	2141.90 (1866.33,2432.16)	110.41 (57.85,200.02)	2.43 (2.04,2.82)

Abbreviations: UI: uncertainty interval; ASR: age-standardised rates; AAPC: Average Annual Percent Change; CI: confidence intervals.

Fig. 1.

Trends in ischemic heart disease prevalence, death, and DALYs from 1990 to 2023 in China in both sexes combined, females and males A, C and E show trends in prevalence, death, and DALYs cases. B, D and E show trends in age-standardised prevalence, death, and DALYs rate. DALYs: Disability-Adjusted Life-Years.

Fig. 2.

The ischemic heart disease patients of each age group (per 5-year cohort) in males and females with prevalence, death, and DALYs number and their age-standardised rate, with the number on the left side and the age-standardised rate on the right side, with females in orange red and males in green) in 2023 in China A. Prevalence. B. Death. C. DALYs. DALYs: Disability-Adjusted Life-Years.

Fig. 3.

Analysis of ischemic heart disease prevalence (A), mortality (B) and DALYs (C) trends from 1990 to 2023 in China DALYs: Disability-Adjusted Life-Years; APC: annual percentage change; AAPC: average APC.

3.2. Mortality analysis and trend of ischemic heart disease

Over the past three decades, the number of ischemic heart disease-related deaths in China increased substantially by 173.76 % (95 % UI: 121.56 %,251.49 %), from 727,481 (95 % UI: 589,332,862,081) in 1990 to 1991,576 (95 % UI: 1684,998,2248,367) in 2023, indicating a growing absolute disease burden; however, the ASMR declined from 112.32 (95 % UI: 91.23,133.63) per 100,000 to 93.19 (95 % UI: 78.67,105.49) per 100,000 during the same period, may reflect advancements in both primary prevention and secondary prevention/clinical care (Table 1 and Fig. 1C, D). Significant disparities were observed across age and gender: mortality increased exponentially with age, and males consistently exhibited higher death numbers and rates than females in most age groups, particularly in middle age, though this gap narrowed among the very elderly, with women surpassing men in the 80+ group (Fig. 2B). Notably, a transient decline in mortality around 2020, potentially linked to COVID-19-related disruptions, was followed by a rebound in 2022–2023. These findings underscore the need for targeted prevention strategies addressing higher risk in middle-aged men and elevated burden among very old women, amid an aging population and changing lifestyle factors. The AAPC was 2.96 % (95 % CI: 2.61 %,3.31 %) (p < 0.001) from 1990 to 2023. Temporal analysis revealed three distinct phases: an initial steady increase by APC=2.04 % (95 % CI: 1.71 %,2.38 %), followed by accelerated growth by APC=4.80 (95 % CI: 4.10 %,5.50 %), and finally a moderated yet significant rise by APC=2.37 (95 % CI: 1.41 %,3.34 %), reflecting dynamic influences from risk factors such as hypertension, diabetes, and smoking (Fig. 3B).

3.3. DALYs analysis and trend of ischemic heart disease

In China, the number of ischemic heart disease-associated DALYs increased substantially from 18,510,283 (95 % UI: 14,827,506,22,256,069) in 1990 to 37,023,944 (95 % UI: 32,947,704,40,787,339) in 2023, representing a rise of 100.02 % (95 % UI: 63.25 %, 157.95 %); however, the ASDR decreased from 2281.61 (95 % UI: 1870.12,2721.98) per 100,000 population to 1694.23 (95 % UI: 1496.51,1865.45) per 100,000 population over the same period (Table 1 and Fig. 1E, F). This burden exhibited significant age and sex disparities: DALYs were negligible under age 15, emerged from age 15–19, and rose sharply with age. The number of ischemic heart disease-associated DALYs peaked in the 70–74 group and 80–84 group in males and females, respectively. The ASDR peaked in 95+ group for both males and females. Across all age groups, males consistently had higher DALYs numbers and rates than female, though this gap narrowed among the very elderly, with women surpassing men in the 80+ group (Fig. 2C). From 1990 to 2023, the trends of DALYs number and ASDR are identical with those in deaths number and ASMR above. The AAPC in DALYs was 1.99 % (95 % CI: 1.67 %, 2.30 %, p < 0.001) from 1990 to 2023, with phase-specific growth rates indicating periods of acceleration and moderation (Fig. 3C).

3.4. Risk factors

Based on the GBD 2023 data, this comprehensive analysis of ischemic heart disease burden in China identifies high systolic blood pressure as the predominant risk factor across all metrics, recording 19,718,369 DALYs, 1098,083 deaths, an ASDR of 889.30 per 100,000 population and ASMR of 51.22 per 100,000 population. It is followed by lead exposure and high LDL cholesterol. Ambient particulate matter pollution also contributes substantially. Among behavioral risks, smoking accounts for 9023,047 DALYs and 366,487 deaths and has a ASDR of 405.97 per 100,000 population and ASMR of 16.38 per 100,000 population, while secondhand smoke remains significant. Key dietary risks include high sodium intake and low whole grain intake. Negative estimates for certain factors such as high alcohol use and low legume intake suggest model uncertainty or possible protective effects and require cautious interpretation. Wide uncertainty intervals underscore the need for careful inference regarding point estimates.

3.5. Decomposition analysis of ischemic heart disease burden

Based on the decomposition analysis of ischemic heart disease in China from 1990 to 2023, the overall prevalence increased by approximately 19,828,469.45 cases, mortality rose by about 575,989.95 deaths, and the overall change showed an increase of 6891,250.90 DALYs. These increases were overwhelmingly driven by population aging, which accounted for 61.76 % of the prevalence rise, 98.15 % of the mortality increase, and 124.46 % of the DALY growth. Population growth also contributed substantially, accounting for 30.75 %, 34.53 %, and 54.20 % of the increases in prevalence, mortality, and DALYs, respectively. In contrast, epidemiological changes, reflecting improvements in prevention, treatment, and risk factor management, moderated the burden by reducing mortality by 32.68 % and DALYs by 78.66 %, though they slightly increased prevalence by 7.49 % (Fig. 4). Thus, while demographic shifts were the dominant driver of the growing burden, epidemiological improvements played a crucial mitigating role in mortality and disability outcomes.

Fig. 4.

Decomposition analysis of changes in the prevalence (A), mortality (B) and DALYs (C) of ischemic heart disease between 1990 and 2023 in China DALYs: Disability-Adjusted Life-Years.

Fig. 5.

Prediction of the ischemic heart disease-related prevalence number at each age group (per 5-year cohort): observed (blue lines) and predicted numbers (red lines).

3.6. Prediction of the ischemic heart disease-related disease burden

Based on BAPC modeling, the results indicated that the number of ischemic heart disease-related prevalence, deaths and DALYs numbers would decrease in 2035. The model predicts that there will be 50,977,160±4017,200, 1496,980±114,886 and 25,461,754±1713,002 prevalence, deaths and DALYs cases in 2035, respectively (Fig. 5, eFigure 1 and eFigure 2). However, there may be upward trends in people of 60+ years of prevalence, death and DALYs numbers.

Central Illustration.

4. Discussion

This study systematically analyzes the trends in disease burden, risk factors, and demographic driving mechanisms of ischemic heart disease from 1990 to 2023. The results indicate that although the ASMR and ASDR show a declining trend, reflecting certain achievements in cardiovascular disease prevention and treatment, the absolute numbers of cases, deaths, and DALYs have increased significantly. This highlights the substantial persistent burden of cardiovascular diseases in China against the backdrop of population aging, growing base populations, and continued exposure to risk factors [[24], [25], [26]].

From gender and age perspectives, the disease distribution exhibits significant heterogeneity. The disease burden among middle-aged men is notably higher than that among women, which may be related to smoking, high-stress lifestyles, low hypertension control rates, and inadequate health service utilization imposed by social roles [27]. In older age groups, however, the prevalence among women and mortality overtake those of men, reflecting the gradual manifestation of cumulative metabolic and vascular risks due to women’s longer life expectancy, as well as indicating gender-specific vulnerabilities in late-life cardiovascular health management [28].

The temporal trend analysis further reveals three distinct phases in the evolution of the disease burden: a period of growth (1990-2000), a phase of decrease (2000–2004), and a subsequent increased period (2004–2023). This dynamic process closely aligns with the implementation of public health policies, the capacity-building of primary healthcare services, and major societal events across different periods in China. The transient decline in mortality observed in 2020, in particular, may be associated with reduced acute respiratory disease mortality and short-term improvements in public health behaviors during the COVID-19 pandemic. However, the subsequent rebound in 2022–2023 serves as a critical reminder that the persistent disruption caused by public health emergencies to chronic disease management systems cannot be overlooked [29].

In terms of risk factors, high systolic blood pressure remains the dominant contributor, with associated burdens of 19,718,369 DALYs and 1098,083 deaths, underscoring the importance of blood pressure control as a key intervention target. Additionally, lead exposure, high LDL cholesterol, and ambient particulate matter pollution are also non-negligible factors, indicating that cardiovascular disease prevention and control must extend beyond traditional medical approaches to include environmental health and policy interventions. Among behavioral factors, smoking continues to impose a significant disease burden, while dietary imbalances, such as high sodium and low whole-grain intake, further exacerbate metabolic disorders. Certain factors, including alcohol and legume intake, show negative estimates, suggesting complex underlying effects that require cautious interpretation based on biological plausibility rather than direct inference as protective measures [[30], [31], [32], [33]].

Decomposition analysis reveals that population aging is the primary driver behind the increasing burden of ischemic heart disease, contributing to over 100 % of the rise in DALYs. This indicates that without the active implementation of preventive and control measures in recent years, the increase in burden could have been even more staggering. Population growth has also contributed to approximately 20 %−30 % of the increased disease burden. In contrast, epidemiological transition, including improved risk factor management, enhanced treatment accessibility, and higher quality of medical care, has significantly mitigated the burden of mortality and disability, leading to a continuous decline in age-standardized rates. This reflects the positive impact of China’s cardiovascular disease prevention and control policies over the past three decades [34,35].

Projections based on the BAPC model suggest that the overall burden may begin to decline by 2035, indicating certain long-term benefits of current prevention strategies. However, the prevalence, mortality, and DALYs related to ischemic heart disease among people aged 60 and above continue to rise, highlighting the severe reality of an aging population with a higher concentration of cardiovascular diseases in older age groups and those with multiple comorbidities. Without more inclusive and integrated care models targeted at this group, their increasing burden could offset the improvements seen in the general population [36].

5. Limitations

This study has several limitations. The GBD data rely on modeled estimates; although the methodology is standardized and continuously refined, the results remain constrained by the quality and coverage of original data, with considerable uncertainties existing in some metrics [19]. Causal relationships between risk factors and diseases require further validation through more detailed mechanistic research and prospective cohort studies. Moreover, policy recommendations need to be adapted to local contexts by accounting for provincial and municipal resource allocation, cultural differences, and social determinants.

6. Conclusions

The burden of ischemic heart disease in China continues to rise under the dual pressures of population aging and risk factors, while demonstrating significant heterogeneity across age, gender, and temporal distributions. Moving forward, effective existing prevention and control strategies should be maintained, with increased attention to aging and gender-specific populations. Efforts should promote precision-based screening and interventions for high-risk groups, strengthen multi-sectoral collaboration to address environmental and behavioral risks, and develop patient-centered integrated cardiovascular health management service systems. These measures are essential to effectively curb the disease burden and comprehensively improve cardiovascular health nationwide.

Funding

The work was funded by Science and Technology Joint Plan Project of Liaoning Province (Project Number: 2024-MSLH-132). The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or the writing of the report.

Data availability free text

This study utilised publicly available data from the Global Burden of Disease 2023 (GBD 2023), released by the Institute for Health Metrics and Evaluation (IHME). The data can be accessed through the Global Health Data Exchange (GHDx) website (https://vizhub.healthdata.org/gbd-results/).

CRediT authorship contribution statement

Changjun Li: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Xinbo Xu: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Conceptualization. Heyan Zhang: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Conceptualization. Haihang Xu: Writing – review & editing, Writing – original draft, Visualization, Validation, Conceptualization. Zhaolong Xu: Writing – review & editing, Writing – original draft, Visualization, Validation, Conceptualization. Qinghua Chang: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. JingFu Bao: Writing – review & editing, Writing – original draft, Conceptualization.

Declaration of competing interest

None.

Appendix. Supplementary materials

eFigure 1. Prediction of the ischemic heart disease-related death number at each age group (per 5-year cohort): observed (blue lines) and predicted rates (red lines)

eFigure 2. Prediction of the ischemic heart disease-related DALYs number at each age group (per 5-year cohort): observed (blue lines) and predicted rates (red lines)