The trends of congenital heart defects burden in BRICS-plus from 1990 to 2021 and its projection to 2035

Abstract

Background

Congenital heart defects (CHDs) are the most common birth defects. Previous studies indicate CHD accounted for approximately 261,247 global deaths in 2017. This study aims to analyze the burden of CHD across BRICS-plus nations from 1990 to 2021 and to project the burden of CHD in the BRICS-plus from 2021 to 2035.

Methods

This is a descriptive observational study analyzing population-level trends in the burden of congenital heart disease across BRICS-plus nations using data from the Global Burden of Disease (GBD) study. The GBD 2021 database was searched to collect the incidence, prevalence, mortality and disability-adjusted life years (DALYs) of CHDs in the BRICS-plus. Trends in the burden of CHD from 1990 to 2021 were analyzed. Additionally, employed Bayesian Age-Period-Cohort (BAPC) model to forecast the incidence, prevalence, mortality, and DALYs rates of CHD by 2035.

Results

From 1990 to 2021, the annual average percentage change (AAPC) in both age-standardized mortality rates (ASMR) and age-standardized disability-adjusted life years rates (ASDR) for coronary heart disease across all BRICS-plus countries remained below zero, indicating a significant downward trend. In the 2021 SDI analysis, SDI showed negative correlations with both ASDR and ASMR of CHD. Males exhibit higher levels of ASMR and ASDR than females. Projections indicate that Russia’s ASIR and the United Arab Emirates’ (UAE) ASPR will show an upward trend from 2021 to 2035.

Conclusion

The BRICS-plus nations continue to face a substantial burden of CHD, with significant variations observed among member states. Notably, several CHD prevention and control strategies implemented across BRICS-plus countries offer valuable models for other developing nations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08858-z.

Introduction

Congenital heart disease (CHD) comprises a spectrum of structural malformations of the heart and great vessels, resulting from errors in embryogenesis [1]. The complexity and severity of these defects vary widely, from common septal defects (ASD, VSD) and conotruncal anomalies (e.g., tetralogy of Fallot) to complex defects requiring early intervention (e.g., single-ventricle physiology) and other anomalies like PDA or valvular disorders [2]. The primary causes of CHD mortality vary by income level. In low-income countries, high mortality is driven by complex defects (e.g., single-ventricle physiology), where resource constraints prevent essential early surgery. In contrast, middle-income nations see mortality predominantly from critical CHD and septal defects. While complex defects remain significant in high-income countries, timely interventions have generally mitigated outcomes [2, 3].

Previous studies indicate CHD accounted for approximately 261,247 global deaths in 2017 [4]. The GBD 2021 reported an annual incidence of 1.3 million neonatal CHD cases globally, with over 25% requiring immediate intervention to mitigate mortality risks [5]. CHD management consumes substantial healthcare resources globally, which accounts for approximately 23% of pediatric healthcare resources worldwide [6]. Relative to high-income countries, the economic burden of CHD, measured as a percentage of GDP, is higher in LMICs [7]. In China (2018–2020), inpatient CHD surgery costs consumed 86–94% of GDP per capita, imposing a substantial financial burden [8]. Established maternal risk factors for CHD include folate deficiency, which impairs DNA synthesis, and obesity, which increases odds by 15–30% [9, 10]. Furthermore, exposure to fine particulate matter (PM₂.₅) is associated with a 51% higher risk of specific defects like tetralogy of Fallot, particularly in early gestation (weeks 3–8) [11, 12].

Notably, disease trajectories differ significantly between high-income countries and LMICs [13]. BRICS is an international cooperation organization of emerging markets and developing countries. The BRICS group (Brazil, Russia, India, China, South Africa) expanded in 2024 to include Saudi Arabia, Egypt, the UAE, Iran, and Ethiopia, and is currently comprised of 10 countries (referred to as BRICS-plus) [14, 15] that account for 46% of the global population, with demographic projections suggesting an increased need for cross-border coordination of health infrastructure [16]. While the expanded BRICS bloc exhibits significant heterogeneity in geography, culture, and socioeconomic systems, its member states face common public health challenges—including aging populations and environmental pollution [17]. A systematic, multidimensional analysis of the CHD burden in BRICS is thus essential. It serves to clarify regional disease patterns, inform targeted prevention in LMICs, and promote equitable resource allocation.

This study synthesized and analyzed the disease burden of CHD worldwide and in BRICS-plus countries from 1990 to 2021 in terms of four dimensions, namely, incidence, mortality, disability-adjusted life year (DALY), and prevalence, using the relevant data provided by the GBD 2021 study on burden and epidemiologic trends. Concurrently, we examine CHD trends in BRICS-plus nations at the Sociodemographic Index (SDI) level. In addition, a 14-year prospective prediction and analysis of the disease burden of CHD in BRICS-plus countries was conducted. This work aims to provide a scientific basis for the development of public health strategies and programs to improve the current status of CHD.

Materials and methods

Data sources

The study employed data from the GBD 2021 repository, accessible via the Global Health Data Exchange platform (GBD Results Tool: https://ghdx.healthdata.org/gbd-2021). GBD 2021 produced estimates for 204 countries and territories, grouped into 21 regions and seven super-regions. GBD regions, and in turn GBD super-regions, are made up of countries and territories that are geographically close, epidemiologically similar, and share similar distributions of causes of death [18]. This comprehensive epidemiological resource provides standardized metrics for 371 health conditions across 204 nations and territories [18–20], constituting the most extensive standardized compilation of health loss data encompassing disease burden, risk factors, mortality, and disability metrics. Methodological innovations in GBD 2021 included integration of 19,189 novel DALYs data sources, incorporation of 12 newly characterized health conditions, and methodological refinements enhancing estimation precision.

The GBD 2021 study employed Disease Modelling MetaRegression (DisMod-MR 2.1), which generates internally consistent estimates based on age, gender, location, and time. Moreover, biases were adjusted by applying correction factors estimated through network meta-regressions employing the Meta-Regression Bayesian, Regularised, Trimmed (MR-BRT) framework [18]. The GBD 2021 database includes epidemiological data on prevalence, incidence, mortality, years lived with disability (YLDs), years of life lost (YLLs), DALYs, and healthy life expectancy (HALE) [20–22]. This study adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) [23].

Research method

CHD is a type of congenital birth defect, defined by the GBD 2021 as any heart disease present at birth. It encompasses a range of structural and functional abnormalities, including but not limited to great vessel anomalies, congenital valvular heart disease, patent ductus arteriosus, ventricular septal defect, atrial septal defect, single ventricle, and single ventricle pathway heart defects, as well as complex congenital heart disease that does not include single ventricle or single ventricle pathway models. In the GBD, CHD is classified according to the International Classification of Diseases (ICD)-10 codes Q20-Q28.9 [5]. ASIR, ASPR, ASMR, and ASDR with corresponding 95% uncertainty intervals (UIs) were extracted from the GBD database for BRICS-plus member states (Brazil, Russia, India, China, South Africa, Saudi Arabia, Egypt, UAE, Iran, Ethiopia) spanning 1990–2021 [24]. AAPC with 95% confidence intervals (CIs) were calculated for these epidemiological indicators. BAPC modeling was subsequently applied to project CHD-related ASIR, ASPR, ASMR, and ASDR trajectories through 2035.

The SDI is a composite metric derived from the geometric mean of three components: total fertility rate among individuals aged < 25 years, mean years of education in populations aged ≥ 15 years, and lag-distributed per capita income. In the GBD 2021 study, SDI values were scaled by 100, yielding a normalized index ranging from 0 (worst) to 100 (best). This synthetic indicator captures socioeconomic development disparities in health determinants across regions. Geographical areas are demarcated into low, low-middle, middle, high-middle, and high SDI categories based on quintiles [25].

Statistical methods

To facilitate comparative analyses of population health metrics across heterogeneous demographic structures and temporal dimensions, age-standardized rates (ASRs) with 95% uncertainty intervals (UIs) were calculated using the direct standardization method. We present estimates in counts and age-standardised rates per 100 000 population using the GBD standard population structure [26]. This methodology employed the reference population from the GBD 2021 [21]. The ASR (per 100,000 population) incorporates four core epidemiological parameters: incidence, prevalence, mortality, and DALYs, calculated through the following formula:

where a_i is the age-specific rate for age group i, and w_i is the weight of the age group in the standard population and A denotes the number of age groups [27].

All calculations were conducted 500 times to generate draw-level estimates. The number of computations per process was reduced from 1000, as in previous GBD iterations, to 500 for GBD 2021 because simulation testing revealed the final estimates and their uncertainty was not affected by this reduction. Final estimates represent the mean estimate across 500 draws, and 95% UIs are represented by the 2.5th and 97.5th percentile values across the draws. Uncertainty was propagated at each step in the estimation process [18].

The AAPC was employed to quantify longitudinal trends in epidemiological indicators, representing the mean annual relative variation across the study period (1990–2021). This study employs the weighted average of slope coefficients from the Joinpoint regression program (version 4.9.1.0) spanning 1990 to 2021, which is subsequently converted to yield annual percentage changes. Statistical significance was determined through 95% CIs, its 95% CI lower bound are both greater than 0, ASRs are considered to be increasing; if the upper bound is less than 0, ASRs are considered to be decreasing; otherwise, ASRs are deemed stable over time. The AAPC calculation followed the standard epidemiological formula:

Where b_i is the slope coefficient for the i^th segment with i indexing the segments in the desired range of years, and w_i is the length of each segment in the range of years [27].

The BAPC model was implemented to project CHD incidence, mortality, and DALYs rates through 2035. The BAPC model extends the generalized linear model (GLM) framework within a Bayesian context, dynamically integrating age, period, and cohort effects. These effects exhibit continuous evolution over time and are smoothed via a second-order random walk, enhancing posterior probability prediction accuracy. A key advantage is its implementation of Integrated Nested Laplace Approximation (INLA) for approximating marginal posterior distributions. This approach circumvents challenges—including mixing and convergence issues inherent in Markov Chain Monte Carlo techniques—while preserving computational efficiency. The model’s flexibility and robustness in analyzing time series data render it particularly suitable for long-term disease burden forecasting. Given its comprehensive temporal trend capture, the BAPC model has undergone extensive validation and application in epidemiological research, especially for age-structured population data and complex cohort effects [28]. This validated analytical framework systematically incorporates age-specific risk profiles, temporal variations, and birth cohort effects, enabling robust projection of disease burden trajectories through integrated estimation of demographic and temporal determinants.

All statistical analyses were conducted using R software (version 4.2.3) and the JD_GBDR package (V2.22, Jingding Medical Technology Co., Ltd.). A p-value < 0.05 was considered statistically significant.

Result

Burden of disease

In 1990, Ethiopia exhibited the highest ASIR of CHD among BRICS-plus nations at 48.824/100,000 (95% UI: 37.223, 64.343). Conversely, the UAE recorded the lowest ASIR at 19.457/100,000 (95% UI: 15.904, 24.539) (Table 1). In 2021, Ethiopia exhibited the highest ASIR of CHD among BRICS-plus nations at 43.568/100,000 (95% UI: 33.342, 58.428), ranking 24th among 204 global jurisdictions (Fig. 1A). Conversely, the UAE recorded the lowest ASIR at 18.999/100,000 (95% UI: 15.288, 24.592) (Table 1). Longitudinal analysis revealed significant ASIR reductions (AAPC < 0) between 1990 and 2021 in Brazil, China, Egypt, Ethiopia, Saudi Arabia, South Africa and the UAE, with China demonstrating the most pronounced decline (AAPC: -0.236, 95% CI: -0.250, -0.223) (Fig. 2; Table 1). Notably, three member states (Ethiopia, India, South Africa) maintained ASIRs exceeding the 2021 global average (37.184/100,000, 95% UI: 29.309, 47.964), while others demonstrated epidemiological advantages through below-average incidence rates. In 2021, BRICS-plus nations exhibited an inverse association between SDI and ASIR of CHD, with lower SDI levels correlating with elevated ASIR (R = − 0.806, P < 0.05) (Figure S1).

Table 1.

ASIR and tends of congenital heart defect in BRICS

Country	Age-standardized incidence per 100,000 population (95% UI)		AAPC (95% CI)
	1990	2021
Brazil	34.709(25.649,48.948)	33.966(25.074,48.607)	-0.023(-0.027,-0.019)
China	39.849(30.672,52.870)	32.755(24.936,44.284)	-0.236(-0.250,-0.223)
Egypt	30.702(25.141,38.426)	30.593(25.129,38.264)	-0.023(-0.035,-0.011)
Ethiopia	48.824(37.223,64.343)	43.568(33.342,58.428)	-0.170(-0.178,-0.162)
India	37.619(29.552,48.682)	39.398(30.980,51.197)	0.070(0.058,0.082)
Iran (Islamic Republic of)	29.267(23.589,36.330)	28.943(23.384,36.025)	0.002(-0.007,0.011)
Russian Federation	30.955(24.450,39.876)	31.148(24.683,39.780)	0.010(0.005,0.015)
Saudi Arabia	24.483(20.749,29.348)	21.932(18.013,27.647)	-0.074(-0.078,-0.070)
South Africa	39.049(29.373,53.874)	37.462(27.989,51.729)	-0.049(-0.056,-0.042)
United Arab Emirates	19.457(15.904,24.539)	18.999(15.288,24.592)	-0.013(-0.021,-0.006)
Global	36.876(29.062,47.822)	37.184(29.309,47.964)	0.009(0.006,0.013)

AAPC: average annual percentage change. An ASR is considered increasing with a lower 95% CI bound above 0, decreasing with an upper bound below 0, and stable otherwise

Fig. 1.

Global Burden of Disease for congenital heart disease in 204 Countries and territories: (A) ASIR, (B) ASPR, (C) ASMR, (D) ASDR

Fig. 2.

Time trend of ASIR in congenital heart disease in BRICS-plus from 1990 to 2021. The red line and its surrounding area represent the projection curves and uncertainty intervals for both sexes in total

Iran demonstrated the highest ASPR of CHD among BRICS-plus nations in 1990 at 265.343/100,000 (95% UI: 237.218, 293.235), while India recorded the lowest prevalence (179.922/100,000; 95% UI: 160.033, 200.051) (Table 2). Iran demonstrated the highest ASPR of CHD among BRICS nations in 2021 at 277.513/100,000 (95% UI: 248.245, 307.428; global rank 34/204) (Fig. 1B), while Ethiopia recorded the lowest prevalence (177.329/100,000; 95% UI: 155.241, 198.124) (Table 2). Longitudinal analysis identified diverging epidemiological trajectories: China, Egypt, India, Iran, Russia, Saudi Arabia, South Africa, and exhibited significant ASPR increases (AAPC > 0) from 1990 to 2021, with the UAE showing the most pronounced growth (AAPC: 0.409; 95% CI: 0.395, 0.422) (Fig. 3; Table 2). Conversely, Brazil, and Ethiopia manifested decreasing prevalence trends (AAPC < 0), with Brazil demonstrating the steepest decline (AAPC: -0.902; 95% CI: -0.921, -0.882). Cross-national comparisons revealed that in 2021, BRICS members excluding Brazil, China, Ethiopia, and India exceeded the global ASPR average (210.701/100,000; 95% UI: 187.921, 232.482). In 2021, BRICS-plus nations exhibited a positive association between SDI and ASPR for CHD, with higher SDI correlating with elevated ASPR (R = 0.552, P > 0.05) (Figure S2).

Table 2.

ASPR and tends of congenital heart defect in BRICS

Country	Age-standardized prevalence per 100,000 population (95% UI)		AAPC (95% CI)
	1990	2021
Brazil	222.693(200.339,244.891)	194.369(175.753,213.257)	-0.902(-0.921,-0.882)
China	189.566(166.464,210.632)	196.027(173.730,216.927)	0.202(0.198,0.206)
Egypt	243.198(213.169,271.774)	254.438(224.005,283.634)	0.337(0.319,0.355)
Ethiopia	181.092(158.834,202.450)	177.329(155.241,198.124)	-0.128(-0.133,-0.123)
India	179.922(160.033,200.051)	189.406(168.833,209.788)	0.307(0.215,0.399)
Iran (Islamic Republic of)	265.343(237.218,293.235)	277.513(248.245,307.428)	0.381(0.369,0.392)
Russian Federation	217.185(194.290,241.723)	217.632(195.271,241.451)	0.016(0.003,0.029)
Saudi Arabia	247.073(223.040,272.400)	248.990(220.434,276.232)	0.042(0.025,0.059)
South Africa	245.256(217.200,276.714)	250.257(221.240,280.150)	0.154(0.143,0.164)
United Arab Emirates	255.369(223.536,285.918)	267.826(236.145,297.917)	0.409(0.395,0.422)
Global	209.530(186.397,231.488)	210.701(187.921,232.482)	0.033(0.027,0.039)

Fig. 3.

Time trend of ASPR in congenital heart disease in BRICS-plus from 1990 to 2021. The red line and its surrounding area represent the projection curves and uncertainty intervals for both sexes in total

Egypt demonstrated the highest ASMR for CHD among BRICS-plus nations in 1990 at 18.944/100,000 (95% UI: 6.600, 28.515), while South Africa recorded the lowest mortality burden (2.822/100,000; 95% UI: 2.311, 3.703) (Table 3). Egypt demonstrated the highest ASMR for CHD among BRICS-plus nations in 2021 at 4.378/100,000 (95% UI: 3.220, 5.797; global rank 44/204) (Fig. 1C), while Saudi Arabia recorded the lowest mortality burden (1.344/100,000; 95% UI: 0.868, 2.091) (Table 3). Temporal analysis revealed consistent ASMR reductions (AAPC < 0) across all BRICS-plus countries during 1990–2021, with Iran showing the most significant decline (AAPC: -0.509; 95% CI: -0.518, -0.501) and South Africa showing the smallest decline (AAPC: -0.028; 95% CI: -0.030, -0.026) (Fig. 4; Table 3). Notably, Egypt’s 2021 ASMR (4.378/100,000; 95% UI: 3.220, 5.797) surpassed the global average (3.860/100,000; 95% UI: 3.190, 4.704), whereas other member states maintained mortality rates below this benchmark. In 2021, BRICS-plus nations exhibited an inverse association between SDI and ASMR of CHD, with lower SDI levels correlating with elevated ASMR (R = − 0.879, P < 0.05) (Fig. S3).

Table 3.

ASMR and tends of congenital heart defect in BRICS

Country	Age-standardized rate (per 100,000)		AAPC (95% CI)
	1990	2021
Brazil	5.280(4.503,6.113)	3.029(2.471,3.647)	-0.075(-0.079,-0.071)
China	11.158(7.052,15.419)	2.716(2.141,3.443)	-0.278(-0.282,-0.273)
Egypt	18.944(6.600,28.515)	4.378(3.220,5.797)	-0.470(-0.479,-0.461)
Ethiopia	8.680(2.369,17.799)	3.504(2.166,6.292)	-0.165(-0.167,-0.162)
India	7.066(4.269,9.472)	3.596(2.658,4.986)	-0.110(-0.113,-0.106)
Iran (Islamic Republic of)	17.685(9.617,23.945)	1.723(1.265,2.375)	-0.509(-0.518,-0.501)
Russian Federation	4.624(4.115,5.654)	1.472(1.197,1.852)	-0.104(-0.109,-0.099)
Saudi Arabia	11.238(6.052,16.098)	1.344(0.868,2.091)	-0.321(-0.323,-0.319)
South Africa	2.822(2.311,3.703)	1.963(1.343,2.808)	-0.028(-0.030,-0.026)
United Arab Emirates	7.936(5.240,10.784)	1.671(0.953,2.288)	-0.198(-0.209,-0.187)
Global	8.507(5.012,10.901)	3.860(3.190,4.704)	-0.151(-0.152,-0.150)

Fig. 4.

Time trend of ASMR in congenital heart disease in BRICS-plus from 1990 to 2021. The red line and its surrounding area represent the projection curves and uncertainty intervals for both sexes in total

Egypt exhibited the highest ASDR for CHD among BRICS-plus nations in 1990 (1683.580/100,000; 95% UI: 588.877, 2533.207), while South Africa demonstrated the lowest disease burden (252.488/100,000; 95% UI: 208.090, 326.282) (Table 4). Egypt exhibited the highest ASDR for CHD among BRICS-plus nations in 2021 (394.339/100,000; 95% UI: 296.591, 520.639; global rank 43/204) (Fig. 1D), while Saudi Arabia demonstrated the lowest disease burden (122.348/100,000; 95% UI: 81.933, 186.271) (Table 4). Temporal analysis identified sustained ASDR reductions (AAPC < 0) across all BRICS countries during 1990–2021, with Iran showing the most significant decline (AAPC: -45.165; 95% UI: -45.953, -44.378) and South Africa showing the smallest decline (AAPC: -2.364; 95% UI: -2.537, -2.192) (Fig. 5; Table 4). Cross-national comparisons revealed Egypt as the sole BRICS-plus member exceeding the 2021 global ASDR average (345.238/100,000; 95% UI: 288.339, 422.159), with other nations maintaining below-benchmark disability burdens. In 2021, BRICS-plus nations exhibited an inverse association between SDI and ASDR of CHD, with lower SDI levels correlating with elevated ASDR (R = − 0.879, P < 0.05) (Fig. S4).

Table 4.

ASDR and tends of congenital heart defect in BRICS

Country	Age-standardized DALYs per 100,000 population (95% UI)		AAPC (95% CI)
	1990	2021
Brazil	471.971(403.246,548.983)	274.126(223.028,330.248)	-6.575(-6.967,-6.184)
China	978.021(617.518,1348.026)	241.683(191.376,304.837)	-24.151(-24.588,-23.715)
Egypt	1683.580(588.877,2533.207)	394.339(296.591,520.639)	-41.624(-42.410,-40.838)
Ethiopia	762.070(204.215,1553.260)	312.366(196.074,555.158)	-14.303(-14.542,-14.064)
India	621.078(377.269,832.516)	321.952(239.508,447.863)	-9.974(-10.292,-9.656)
Iran (Islamic Republic of)	1581.075(863.234,2136.618)	162.836(121.276,218.586)	-45.165(-45.953,-44.378)
Russian Federation	414.427(368.414,512.855)	133.977(108.562,165.612)	-9.300(-9.726,-8.874)
Saudi Arabia	995.641(536.497,1423.986)	122.348(81.933,186.271)	-28.341(-28.502,-28.181)
South Africa	252.488(208.090,326.282)	179.513(123.368,254.555)	-2.364(-2.537,-2.192)
United Arab Emirates	703.081(467.753,950.246)	158.171(98.655,212.532)	-17.276(-18.216,-16.335)
Global	750.300(440.935,960.106)	345.238(288.339,422.159)	-13.224(-13.341,-13.107)

Fig. 5.

Time trend of ASDR in congenital heart disease in BRICS-plus from 1990 to 2021. The blue line and its surrounding area represent the projection curves and confidence intervals for males; The green line and its surrounding area represent the projection curves and uncertainty intervals for females; The red line and its surrounding area represent the projection curves and uncertainty intervals for both sexes in total

Gender-stratified analysis revealed consistent male predominance in CHD-related ASMR and ASDR across all BRICS-plus nations during 1990–2021 (Fig. S5, Fig. S6). In 2021, among males, Egypt had the highest ASMR (4.587/100,000; 95% UI: 3.256, 6.330) and ASDR (413.001/100,000; 95% UI: 296.395, 569.081) for congenital heart disease among the BRICS-plus countries, whereas Saudi Arabia had the lowest ASMR (1.329/100,000; 95% UI: 0.690, 2.327) and ASDR (120.123/100,000; 95% UI: 66.253, 209.639) (Table S1A, Table S2A). Among females, Egypt had the highest ASMR (4.159/100,000; 95% UI: 2.821, 5.660) and ASDR (374.760/100,000; 95% UI: 296.592, 506.861) for congenital heart disease among the BRICS-plus countries, whereas Russia had the lowest ASMR (4.159/100,000; 95% UI: 2.821, 5.660) and ASDR (116.953/100,000; 95% UI: 92.837, 133.579) (Table S1B, Table S2B). Distinct sex-specific patterns emerged in ASIR, with Brazil, China, Egypt, and the UAE demonstrating male-biased distribution, whereas Ethiopia, Iran, and South Africa exhibited female-predominant incidence patterns (Table S3A, Table S3B, Fig. S7). ASPR analyses showed female excess in all BRICS-plus members except China and Russia, which maintained comparable prevalence between genders (Table S4A, Table S4B, Fig. S8).

Projection of disease burden trends

Projected epidemiological trends analysis reveals distinct patterns among BRICS-plus nations during 2021–2035. ASIR, ASPR, ASMR, and ASDR are projected to exhibit declining trajectories in Brazil, China, Egypt, Ethiopia, India, Iran, Saudi Arabia, and South Africa (Fig. S9-16). Russia’s ASPR, ASMR, and ASDR are projected to decline throughout 2022–2035. Conversely, the ASIR will decrease during 2021–2022 but exhibit a slight increase from 2022 to 2035 (Fig. 6A). The UAE displays decreasing ASIR and ASMR alongside rising ASPR, with ASDR characterized by initial increase (2021–2022) followed by sustained decline (2023–2035) (Fig. 6B).

Fig. 6.

Projection of congenital heart disease ASIR, ASMR, ASMR, and ASDR trends in BRICS-plus from 2021 to 2035. The blue area represents 95% UI. A Russian Federation; B United Arab Emirates

Notably, India is projected to maintain the highest CHD-specific ASDR [242.014 per 100,000 (95% UI: 132.729, 351.299)] and ASMR [3.119 per 100,000 (95% UI: 1.406, 4.832)] among BRICS-plus nations by 2035 (Fig. S9), while Ethiopia shows peak ASIR [41.537 per 100,000 (95% UI: 25.603, 57.472)] (Fig. S10) and Iran exhibits maximum ASPR [273.708 per 100,000 (95% UI: 257.741, 289.675)] (Fig. S11). Conversely, China demonstrates the lowest ASIR [8.752 per 100,000 (95% UI: -9.717, 27.220)] (Fig. S12), Ethiopia the minimal ASPR [167.079 per 100,000 (154.372, 179.786)] (Fig. S10), and Iran the lowest ASMR [0.157 per 100,000 (95% UI: 0.098, 0.216)] and ASDR [14.838 per 100,000 (95% UI: 11.694, 17.983)] (Fig. S11) within the BRICS-plus cohort by the target year.

Discussion

The GBD 2021 reveals substantial epidemiological transitions in CHD burden across BRICS-plus nations over three decades. While emerging as a strategic multilateral coalition influencing global governance, these countries confront synergistic public health challenges stemming from a confluence of demographic shifts (population aging), epidemiological pressures (recurrent disease outbreaks), socioeconomic transformations (accelerated urbanization and lifestyle modifications), and structural constraints in healthcare infrastructure development [29, 30]. GBD 2021 estimates indicate BRICS-plus nations collectively accounted for 35.2% (deaths), 41.1% (prevalence), 31.9% (incidence), and 27.9% (DALYs) of global CHD burden in 2021. Notably, significant intercountry heterogeneity persists in both current CHD burden metrics and projected epidemiological trajectories.

Analysis of CHD trends across the BRICS-plus nations reveals a shared trajectory shaped by technological advancement, yet marked by distinct epidemiological patterns reflecting national contexts. A universal driver is the remarkable progress in medical technology, leading to consistent declines in ASMR and ASDR through improved prenatal diagnosis, neonatal surgery, and chronic care [31]. Paradoxically, this success fuels a key divergence: while some countries (e.g., China, Brazil) show falling ASIR, others (e.g., India, Russia) face rising or stable rates, largely determined by the balance between primary prevention and diagnostic sensitivity. Consequently, most nations exhibit rising ASPR, as enhanced detection and prolonged survival expand the registered patient population. The following country-specific discussions elucidate how these global trends are modulated by local policies, healthcare infrastructure, and unique risk factors.

As the largest and most populous nation in Latin America, Brazil demonstrated negative AAPC in ASIR, ASPR, ASMR, and ASDR for CHD during 1990–2021. BAPC modeling predicts continued declines in ASIR, ASMR, and ASDR from 2021 to 2035. Notably, ASPR is projected to exhibit a transient increase in 2021 followed by sustained reductions through 2035. Three policy-driven mechanisms underlie these epidemiological trends: First, nationwide implementation of pulse oximetry screening (“Little Heart Test”) in 2014 enhanced early detection of severe CHD, enabling pregnancy termination or neonatal interventions that reduced live-birth morbidity [32]. Second, integration of fetal echocardiography with advanced imaging modalities (e.g., FINE technique) improved prenatal diagnosis of cardiac anomalies in high-risk pregnancies [33–35]. Third, the 2017 CHD Assistance Program established comprehensive perinatal-to-postsurgical care pathways, mitigating treatment delays from socioeconomic disparities [32]. Concurrently, environmental interventions (e.g., industrial emission controls) and nutritional strategies (folic acid fortification) attenuated teratogenic risks [36]. The 2020–2021 COVID-19 pandemic temporarily disrupted this trajectory: Delayed non-emergency surgeries and restricted prenatal screening in embargo-affected regions caused diagnostic backlogs, manifesting as the 2021 ASPR anomaly [34]. This transient fluctuation highlights the interplay between systemic healthcare capacity and exceptional public health crises. Brazil’s CHD burden reduction reflects synergistic effects of technological advancement, policy innovation, and socioeconomic development. Sustaining this positive trajectory requires optimized regional healthcare resource allocation and targeted mitigation of environmental-genetic risk factors.

As the world’s third-largest nation by land area and second-largest economy, China exhibited negative AAPC in ASIR, ASMR, and ASDR for CHD between 1990 and 2021, while demonstrating positive AAPC values for ASPR. BAPC modeling forecasts declining trends for all four indicators (ASIR, ASPR, ASMR, ASDR) from 2021 to 2035, with China achieving the most substantial ASIR reduction among BRICS-plus nations during 1990–2021. It has been shown that the detection rate of fetal cardiac malformations (e.g., ventricular septal defect, atrial septal defect, etc.) is improved by high-resolution imaging, and the detection sensitivity is increased from 65.22% to 91.30% in conventional 2D ultrasound [37]. This has allowed for early intervention in high-risk pregnancies, with some families opting for termination, reducing the incidence of CHD in live births. Second, China’s birth defects surveillance has been advanced from 28 weeks to 20 weeks of gestation to include more early cases. For example, the proportion of CHD cases diagnosed before 28 weeks of gestation rose from 15% to 28% of CHD cases in Zhejiang Province from 2014 to 2018 [38]. This may account for the increased prevalence. The widespread use of fetal echocardiography in mid-pregnancy has led to increased rates of prenatal diagnosis of complex CHD (e.g., transposition of the great arteries), optimization of perinatal management, and significant reductions in neonatal mortality. For example, postoperative in-hospital mortality was 40% lower in prenatally diagnosed children with CHD than in the undiagnosed group [39, 40]. In addition, the number of cardiac surgery centers in China has increased, with an average annual growth rate of 12% in surgical volume (2010–2019), and the success rate of complex CHD surgeries has increased from 70% to more than 90%, with the postoperative hospital mortality rate decreasing from 8.2% in 2006–2012 to 3.5% in 2017–2019 [41], these advances in surgical techniques may be responsible for the decline in mortality rates. The shift in the epidemiologic trend of CHD in China is the result of a synergistic effect of multiple factors, with early screening reducing new cases, technological advances lowering mortality rates, and the accumulation of surviving patients pushing up the current rate. In the future, with the improvement of the tertiary prevention system and technological innovation, it is expected that all indicators will enter a downward pathway, providing an important reference for global birth defect prevention and control.

Egypt is the third largest economy in Africa. During 1990–2021, the AAPC of ASIR, ASMR and ASDR for CHD in Egypt were less than 0; the AAPC of ASPR were greater than 0. According to the BAPC model, ASIR, ASMR and ASDR for CHD in Egypt will show a decreasing trend in 2021–2035. Whereas ASPR will have an increasing trend in 2021–2025 and a decreasing trend in 2025–2035. Egypt has significantly reduced the mortality rate from CHD through prenatal screening for CHD and advances in neonatal surgery, such as the spread of prenatal ultrasound technology, which has made it possible to diagnose and terminate pregnancies in severe cases at an early stage [42] and improved neonatal surgical success directly reduces mortality rates [43]. Widespread availability of echocardiography and genetic testing has led to more cases of mild or atypical CHD being diagnosed [42]. For example, subtypes such as Patent Ductus Arteriosus (PDA), which had previously been easily under-diagnosed, were included in the statistics, indirectly pushing up the prevalence rate [44]. In addition, long-term management of adult CHD patients (e.g., valve repair and interventions) prolongs patient survival and reduces premature deaths [45]. This may explain the largest increase in prevalence in Egypt among the BRICS-plus countries. The decline in CHD mortality and DALYs in Egypt is largely attributed to medical technology innovations and public health policies, while the increase in prevalence is a combination of improved diagnostic capacity and longer patient survival. In the future, surgical success rates need to be further improved, prenatal diagnosis needs to be optimized, and governance needs to be strengthened in order to improve the overall epidemiological burden of CHD.

Ethiopia is the fifth largest economy and the second most populous country in Africa. The AAPC of ASIR, ASPR, ASMR and ASDR of CHD in Ethiopia were less than 0 during 1990–2021; based on the BAPC modeling it was predicted that ASIR, ASPR and ASMR, ASDR of CHD in Ethiopia will show a decreasing trend during 2021–2035. Ethiopia prioritized communicable disease control and maternal and child health after the 1991 civil war, but has gradually increased its focus on NCDs since 2010. The Action Plan for the National Strategy for the Prevention and Control of Non-communicable Diseases, released in 2014, explicitly includes CHD in the scope of priority prevention and control, promoting the standardization of screening, diagnosis and treatment [46]. Secondly, Ethiopia has been able to expand the coverage of health services, with studies showing that the expansion of cardiac services from the capital to major towns and the increase in the number of private and public hospitals have alleviated the shortage of health resources [46]. Studies have shown that between 1990 and 2016, Ethiopia’s maternal mortality rate declined by 75 per cent, the under-five mortality rate declined by 67 per cent, and life expectancy increased from 45 to 64 years, reflecting progress in the overall health system [47]. Ethiopia’s promotion of antenatal screening through community health workers and early newborn screening for CHD (e.g., heart murmur detection) in some regions has allowed for early intervention and reduced the readmission of mildly ill patients, and these improvements have indirectly reduced the risk of complications and mortality among CHD patients [48, 49]. The decline in the burden of CHD in Ethiopian children is the result of a combination of public health policy transformation, medical technology upgrading and socio-economic development, which provides an important reference for global birth defects prevention and control.

India is the largest country in the South Asian subcontinent, the world’s most populous country and the fifth largest economy in the world. During 1990–2021, the AAPC of ASMR and ASDR for CHD in India were less than 0; the AAPC of ASIR and ASPR were greater than 0. ASIR, ASPR, ASMR and ASDR for CHD in India are projected to be on a declining trend from 2021 to 2035 according to the BAPC model. Widespread availability of diagnostic technologies such as echocardiography in India has led to more detection of mild or asymptomatic CHDs [50]. Second, while the use of fetal cardiac ultrasound is limited in rural India, the diagnostic rate is significantly higher in urban areas [51] and the high prevalence of metabolic diseases such as diabetes and obesity in India further exacerbate the risk during pregnancy [52]. This may explain the continuous increase in ASIR and ASPR for CHD in India from 1990 to 2021. Whereas, improved surgical success rates, public health policy interventions have collectively contributed to the decline in ASDR and ASMR for CHD in India. Indian pediatric cardiac surgery mortality rate declined from 12% in 1988–2002 to 3.92%, thanks to perioperative nutritional management, international collaborations (e.g., the IQIC program), and the spread of complex surgeries (e.g., the Fontan procedure) [53, 54]. Reduced risk of neonatal defects and indirectly reduced CHD-related complications through the promotion of antenatal check-ups, vaccinations and folic acid supplementation by community health workers (ASHAs) [55]. India’s National Non-Communicable Disease Control Scheme (NPCDCS), which has strengthened screening and secondary prevention of CHD and improved management coverage of high-risk populations (e.g., pregnant women with diabetes) [56]. The rise in ASIR and ASPR reveals a lag in maternal health management during modernization, while the decline in ASMR and ASDR is attributed to technological advances and policy interventions. The projected future downward trend relies on continued intensification of preventive measures, equitable distribution of healthcare resources, and data-driven precision prevention and control. This model serves as a reference for other low- and middle-income countries in addressing the burden of CHD.

Iran is located in the heart of Western Asia. The AAPC for ASMR and ASDR for CHD in Iran, 1990–2021, were both less than 0; the AAPC for ASPR were greater than 0; and the 95% uncertainty intervals for the AAPC for ASIR contained 0. According to the BAPC model, ASIR, ASMR, and ASDR for CHD in Iran are predicted to show a decreasing trend, while ASPR is predicted to show an increasing trend in the period 2021–2035. The 95% confidence intervals for ASIR contain 0, suggesting a small magnitude of change or high data heterogeneity. This may be due to missed visits or poor registration systems in some remote areas [57]. Advances in fetal and newborn screening technologies (e.g., high-resolution echocardiography) have identified more mild or asymptomatic cases, expanding the scope of the disease population [19]. Advances in therapeutic techniques (e.g., interventional procedures and extracorporeal membrane oxygenation (ECMO) support) have significantly prolonged patient survival, and the accumulation of chronic cases has pushed up prevalence rates [58]. Iran’s ECMO support effectiveness reaches international level after 2016 [58], study shows. Iran has made significant progress in the field of CHD treatment, such as the gradual introduction of neonatal Ross surgery, double switch surgery and Norwood surgery after 2003 [58]. After 2015, the team completed 350–400 pediatric cardiac surgeries per year, with mortality rates decreasing yearly, and the introduction of technologies such as ECMO further reducing the risk of postoperative complications [58]. Second, Iran’s Health Transformation Plan, implemented in 2014, has reduced out-of-pocket costs for patients and increased hospitalization rates and access to health care services [59], while interdisciplinary collaboration (e.g., Fetal Cardiology Service FCS) has optimized the process of diagnosis and treatment [58]. Surgical advances, policy support and improved medical accessibility have contributed to the decline in ASMR and ASDR of CHD in Iran. The epidemiologic trend of CHD in Iran is the result of a combination of medical advances, policy interventions, and demographic changes. Continued optimization of prenatal screening and balancing of healthcare resources are needed in the future to consolidate the gains.

Russia is the largest country in the world in terms of area. During 1990–2021, the AAPC of ASMR and ASDR for CHD in Russia were less than 0; the AAPC of ASPR and ASIR were greater than 0. According to the BAPC model, ASPR, ASMR and ASDR for CHD in Russia are predicted to show a decreasing trend in 2021–2035; ASIR will show a decreasing trend in 2021–2022 and a mild increasing trend in 2022–2035. The continued decline in ASMR and ASDR for CHD in Russia may be associated with advances in surgical techniques and upgrades in medical equipment. The “Healthy” State project in Russia, launched in 2006, promotes the development of a network of vascular centers and specialized surgeries, which has led to a significant increase in the number of cardiac surgeries and a sustained decline in the surgical mortality rate from its high level in 1990 [60]. For example, the CHD Surgery Program had completed 16,000 cases in 2013, with a reduced mortality rate [61]. Large-scale procurement of modern equipment (e.g., interventional cardiology equipment) after 2000, which has led to a significant reduction in the in-hospital mortality rate for heart-related diseases [62, 63]. Expansion of the Russian newborn screening program to 39 diseases (e.g., in the Moscow region), with increased rates of early diagnosis and avoidance of serious complications in some cases through intervention [61, 64]. However, increased diagnostic sensitivity may also lead to increased ASIR statistics [64]. Studies show that the proportion of the population aged 0–14 declined from 30% to 18% between 1990 and 2020 [65]. A decline in the proportion of children in the population may reduce the number of new cases of CHD. However, there was no significant decrease in ASIR in the actual data, probably because the effect of the decrease in the population base was offset by an increase in the diagnosis rate. Russia, because of its special industrial structure (the energy and metallurgical sectors are prominent) [66, 67]. Second, Russia has not effectively pursued the technological transformation of pollution sources, which has led to a high level of emissions intensity [68]. Exposure to air pollutants (PM2.5, PM10) and chemicals (e.g., pesticides, PCBs) may increase the risk of fetal heart malformations [69–71]. The rising trend of ASIR may be exacerbated if industrial pollution and chemical exposures are not effectively controlled [69, 70]. The changing burden of CHD in Russia is the result of a combination of medical advances, demographics, environmental risks, and data quality. Continued optimization of healthcare resource allocation and strengthening of environmental regulation are needed in the future.

Saudi Arabia is the second largest economy in the Middle East. AAPC less than 0 for ASIR, ASMR and ASDR; AAPC greater than 0 for ASPR for CHD in Saudi Arabia between 1990 and 2021. According to BAPC projections, ASIR, ASPR, ASMR and ASDR of CHD in Saudi Arabia are on a declining trend from 2021 to 2035. Saudi Arabia has implemented a universal newborn CHD screening program since 2016 for early identification of severe cases through pulse oximetry testing (POS) [72, 73]. The accumulation of complex cases of CHD can be reduced through early intervention, thereby reducing overall morbidity. The rollout of antenatal fetal anomaly scanning (AFAS) has enabled the diagnosis of complex CHDs (e.g., tetralogy of Fallot) during pregnancy and optimized the timing of treatment through prenatal counseling and birth planning [74]. This may account for the decreased ASMR and ASDR in CHD. Prolonged Patient Survival Leads to Passive Increase in Prevalence Statistics [75]. Saudi Arabia has a higher proportion of young people and preventive measures reach more people of childbearing age [76]. Projections of future downward trends may depend on the persistence of public health policies.

Located at the southernmost tip of the African continent, South Africa is the second largest economy in Africa and the most economically developed and industrialized country in Africa. Between 1990 and 2021, the AAPC for ASIR, ASMR and ASDR for CHD in South Africa are all less than 0. The AAPC for ASPR are all greater than 0. According to the BAPC model, ASIR, ASPR, and ASMR for CHD in South Africa are projected to trend downward from 2021 to 2035; ASDR rises in 2021–2022 and then declines in 2023–2035. Screening technologies such as echocardiography are gradually being introduced in the South African public health system (15,385 ultrasound examinations per year in public hospitals) [77], reduction of patients with severe disease due to missed diagnosis through early identification of asymptomatic cases [78]. This is despite the fact that surgical resources in South Africa are limited, with, for example, only 800 congenital heart surgeries per year in public hospitals [77], However, universal access to medication and primary care has reduced acute mortality rates [79]. These factors have led to a downward trend in ASIR, ASMR and ASDR for CHD in South Africa. In addition, the increase in prevalence may be due to an increase in cumulative cases as a result of improved patient survival and improved treatment to prolong patient survival. For example, in South Africa, survival after surgery for CHD has improved, but inadequate management of long-term complications pushes up the prevalence rate [77]. South Africa will decline in the future through enhanced preventive measures and advances in medical technology, such as the South African National Health Insurance (NHI) program, which promotes primary health care coverage, reducing the risk of congenital anomalies through prenatal screening and health education [80], and mHealth platforms (e.g., Cathchat) and teleconsultations that improve diagnostic efficiency at the grass-roots level and reduce underdiagnosis [81].

The UAE is located at the southeastern tip of the Arabian Peninsula. It also has the highest GDP per capita in the Middle East. From 1990 to 2021, the AAPC for ASIR, ASDR, and ASMR of CHD in the UAE were less than 0, while the AAPC for ASPR was greater than 0. ASIR and ASMR for CHD in the UAE are projected to trend downward from 2021 to 2035 according to the BAPC model; ASDR is projected to increase in 2021–2022 before decreasing in 2023–2035; and ASPR is projected to trend upward. Neonatal pulse oximetry screening has been widely implemented in the UAE since 2010 [82, 83], which has significantly increased the rate of early diagnosis of severe CHD. Mortality has been reduced by early intervention (e.g., surgery, catheterization). Foreign workers make up 89% of UAE’s population [84], their medical data may not be fully included in the statistics, leading to data heterogeneity and statistical bias that underestimates the incidence rate. Advanced treatments (e.g., ECMO, hybrid surgery) have prolonged patient survival, resulting in an increased proportion of CHD patients surviving childhood into adulthood [85]. Second, improved screening techniques have allowed more asymptomatic or mild CHDs (e.g., small ventricular septal defects) to be diagnosed and included in prevalence statistics [83]. Under the influence of these factors, the ASPR is expected to continue rising in the future. Epidemiological trends of CHD in the UAE reflect a game between advances in medical technology and demographic changes: early screening and tertiary care reduce mortality rates, changes in diagnostic criteria and improved survival rates increase prevalence rates, and BAPC model predictions suggest that continued investment in chronic disease prevention and control, data integration, and ethical frameworks are needed in order to achieve a manageable disease burden in the long term.

The epidemiological trajectory of coronary heart disease in BRICS countries and partner nations is closely linked to the foundational capabilities of their healthcare systems, including funding, service accessibility, and human resource allocation [31]. In the SDI analysis of BRICS-plus nations for 2021, the SDI showed a negative correlation with both the ASDR and ASMR of CHD. This aligns with global trends observed in CHD-SDI analyses [5]. Low-SDI countries face scarcity of medical resources, particularly in cardiac specialty services and surgical facilities. For instance, access to cardiac surgery in low-income nations is significantly lower than in high-income countries/regions, preventing CHD patients from receiving essential treatments [86, 87]. Furthermore, in low-to-middle SDI countries, low rates of regular prenatal check-ups hinder early detection of fetal abnormalities [88]. Conversely, in high-SDI countries, routine fetal echocardiography coverage exceeds 90%, enabling identification of complex CHD as early as the second trimester [2]. Additionally, high-SDI countries employ multidisciplinary collaboration to develop individualized treatment plans, thereby enhancing surgical success rates [86]. Our SDI analysis reveals that low-SDI countries are advised to prioritize enhancing primary prenatal screening systems and neonatal emergency care capabilities, whereas high-SDI nations should direct efforts toward standardizing the quality of regional healthcare. BRICS-plus members need to formulate CHD prevention strategies tailored to their specific SDI levels to mitigate internal disparities.

Regarding gender stratification, males show higher ASMR and ASDR for CHD, consistent with studies conducted in the Global [5]. The underlying reasons for this disparity are not fully understood, but several factors may contribute to this observation. First, males may be more susceptible to severe subtypes of CHD (such as hypoplastic left heart syndrome), leading to higher mortality rates [89]. Additionally, Sex chromosomes (e.g., the X-chromosome protective mechanism) may confer greater resistance to certain congenital anomalies in females, resulting in higher mortality among males [90]. Moreover, males exhibit higher rates of smoking, greater exposure to high BMI, and a higher proportion of unhealthy diets [31], potentially exacerbating the risk of post-operative complications in CHD. For example, in BRICS-plus countries, the ASMR for cardiovascular disease (CVD) mortality in males is 5.3 times and 1.5 times higher than in females due to smoking and dietary risks, respectively [31]. These findings underscore that gender-specific differences are a critical factor that cannot be overlooked in the management and treatment of CHD.

There are some limitations to this study, first, GBD estimates are uncertain, particularly in low-income settings where under-reporting and diagnostic gaps may affect accuracy. Second, the observed correlation between SDI and CHD burden is based on a limited sample of only 10 countries, which inherently reduces its statistical robustness; coupled with the ecological nature of the analysis, this means the association represents a plausible hypothesis rather than proven causal evidence. Third, burden projections based on the BAPC model assume that existing healthcare policies and socioeconomic conditions are stable, but the BRICS-plus countries are undergoing rapid change, and policy fluctuations may lead to biased projections. In addition, the ongoing impact of the COVID-19 outbreak on prenatal screening (e.g., a 27% decline in screening rates in India from 2020–2022 [91]) was not fully incorporated into the model and may underestimate short-term burden fluctuations. Last but not least, as the GBD data for BRICS countries are aggregated at the national level, they obscure critical intra-national disparities (e.g., regional and urban-rural differences) and lack granular information on CHD-specific risk factors, thereby preventing a visual analysis of their contribution to the disease burden.

Conclusion

Substantial disparities in CHD prevention and control systems were observed among BRICS-plus nations despite their shared emerging economy status. These variations originate from multifactorial determinants including heterogeneous cultural traditions, divergent economic models, demographic disparities, and distinct healthcare policy frameworks. Systematic analysis of these determinants enables member states to develop evidence-based health strategies and enhance precision in medical resource allocation. Notably, although CHD management remains challenging, combined strategies—including enhanced neonatal screening(e.g., pulse oximetry), tiered therapeutic networks, specialized cardiothoracic centers, and advanced minimally invasive techniques—offer a viable pathway to sustainably reduce the disease burden. Strategic priorities should be tailored to SDI levels, with low-SDI countries needing to reinforce primary prenatal screening and neonatal emergency networks, and high-SDI countries requiring a focus on standardizing regional healthcare quality. BRICS-plus members must develop SDI-adapted CHD prevention strategies to reduce internal disparities. These evidence-based interventions provide valuable insights for global health policymakers in developing nations. To precisely quantify CHD burden, future research should elucidate risk factors and mechanisms driving epidemiological trends while evaluating targeted interventions. Focused strategies for high-risk populations are essential for early detection, effective clinical management, and reducing population-level CHD burden.

Abbreviations

AAPC

Average annual percent change

ASDR

Age-standardized DALYs rate

ASIR

Age-standardized incidence rate

ASMR

Age-standardized mortality rate

ASPR

Age-standardized prevalence rate

ASR

Age-standardized rate

BAPC

Bayesian age-period-cohort

BRICS

Brazil, Russin Federation, India, China, and South Africa

BRICS-plus

Brazil, Russian Federation, India, China, South Africa, Saudi Arabia, Egypt, United Arab Emirates, Iran, and Ethiopia

CHD

Congenital heart disease

CIs

Confidence intervals

DALYs

Disability-adjusted life years

ECMO

Extracorporeal Membrane Oxygenation

GBD

Global Burden of Disease

LMICs

Low- and middle-income countries

SDI

Socio-demographic Index

UIs

Uncertainty intervals

UAE

United Arab Emirates

Authors’ contributions

All authors made significant contributions to this study. JYY was responsible for the formal analysis, creation of visualizations, and drafting of the original manuscript. YZ and ZCX were involved in data compilation, investigation, review, and editing of the manuscript. ZL was involved in project supervision and manuscript review. LL was involved in the creation of visualizations. XF and YPW were involved in the formal analysis, sourcing, and manuscript editing. QWW was involved in supervision, methodology, project management, and manuscript review and editing. QWW was involved in supervision, methodology, project management, and manuscript review and editing. All authors have read and approved the final manuscript.

Funding

This study was supported by the Youth Teacher Training Project of Education Department of Anhui Province (No. JWFX2024028 to Qiwen Wu) and Anhui Province Key Clinical Specialist Construction Programs.

Data availability

The GBD data can be accessed online through the GHDx portal (https://vizhub.healthdata.org/gbd-results/), a comprehensive database for retrieving and analyzing health-related data and the primary data source for this study.

Declarations

Ethics approval and consent to participate

This study performed secondary analysis of deidentified, aggregate-level population data obtained from the publicly accessible Global Burden of Disease Study 2021 (GBD 2021) repository. The research qualified for ethics review exemption, as it exclusively utilized pre-existing, anonymized epidemiological records without individual-level identifiers or researcher-participant interaction.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.