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International Journal of Women's Health logoLink to International Journal of Women's Health
. 2026 Mar 30;18:588257. doi: 10.2147/IJWH.S588257

Global, Regional, and National Burden and Trends of Hypertensive Heart Disease Among Women of Childbearing Age from 1992 to 2021

Jinglei Huang 1,*, Wenkai Jiang 2,*, Jiawei Zhai 1, Kangting Zhang 3, Guang Yao 4,✉
PMCID: PMC13048066  PMID: 41938183

Abstract

Background

Hypertensive heart disease (HHD) is an important contributor to cardiovascular morbidity among women of childbearing age (WCBA), yet long-term global trends in this population remain insufficiently characterized. We aimed to describe the prevalence, mortality, and disability-adjusted life years (DALYs) of HHD among WCBA at global, regional, and national levels and to assess temporal patterns from 1992 to 2021.

Methods

Data were obtained from the Global Burden of Disease (GBD) 2021 study. We estimated numbers and age-standardized rates of prevalence, mortality, and DALYs for women aged 15–49 years. An age-period-cohort (APC) model was applied to disentangle age, period, and cohort effects on mortality trends.

Results

From 1992 to 2021, the global burden of HHD among WCBA exhibited a divergent trend: while the prevalence rate increased steadily from 20.09% to 27.94%, mortality and DALY rates generally declined. In 2021, significant regional disparities existed, with the middle-SDI region recording the highest prevalence, whereas the high-middle SDI region achieved the lowest mortality and DALY rates. APC analyses for mortality further clarified these shifts: period-effect risks declined across most SDI groups but notably increased in high-SDI countries. Similarly, while cohort-effect risks significantly reduced in most regions, high-SDI countries exhibited a distinct pattern of an initial risk rise followed by a subsequent decline.

Conclusion

Global HHD trends among WCBA are characterized by rising prevalence alongside declining mortality and DALY rates. Marked disparities persisted across SDI regions, with the highest prevalence in middle-SDI settings and more variable mortality patterns in high-SDI settings.

Keywords: hypertensive heart disease, women of childbearing age, global burden of disease, age-period-cohort model

Introduction

In recent years, the world has experienced significant demographic changes marked by an aging population and overall growth, which have contributed to a decline in mortality rates from communicable diseases while simultaneously increasing the prevalence of noncommunicable diseases (NCDs).1 NCDs, recognized as a primary contributor to death and adverse health outcomes, are incorporated into the Sustainable Development Goals (SDGs), specifically aiming to reduce premature mortality linked to NCDs by one third relative to 2015 levels by the year 2030, through enhanced prevention, treatment, and the promotion of mental well-being.2 In this context, hypertensive heart disease (HHD) has gained substantial attention as a significant threat to human health.3 Among NCDs, cardiovascular diseases account for a large share of morbidity and mortality, and hypertension is one of the most important modifiable risk factors; therefore, HHD represents a key hypertension-related cardiovascular outcome that warrants focused attention in women of childbearing age. Between 1992 and 2021, the worldwide number of HHD cases surpassed 18.5 million. This condition is mainly driven by chronic, poorly managed blood pressure, leading to detrimental changes in heart structure and function, and it places considerable physical, psychological, and economic strains on affected individuals and their families.4

Given that cardiovascular disease remains a leading cause of morbidity and mortality among women worldwide, understanding the contribution of HHD to the female cardiovascular burden is of particular importance.5 WCBA exhibit distinct physiological characteristics and lifestyle factors, resulting in unique specificities in HHD regarding risk profiles, clinical manifestations, and disease progression.6 HHD can adversely affect the physical health of women of reproductive age through structural and functional cardiac alterations that are associated with complications such as heart failure and arrhythmias, and it has been linked to increased maternal health risks. Additionally, chronic psychological stress related to caregiving responsibilities, together with sedentary behavior and suboptimal dietary patterns, has been associated with elevated cardiovascular risk and may increase susceptibility to HHD in this population.7 The disease is also associated with impaired mental health and reduced health-related quality of life. Socioeconomically, HHD has been linked to increased healthcare utilization, reduced work productivity, and greater financial burden on families and society.8 Furthermore, female-specific conditions such as polycystic ovary syndrome (PCOS) have been associated with adverse cardiometabolic profiles and may contribute to increased cardiovascular risk, although the direct causal pathways linking these factors to HHD remain incompletely understood.9 Despite growing recognition of cardiovascular risks in women of reproductive age, existing studies have largely focused on hypertension or cardiovascular diseases in the general population, with limited attention to hypertensive heart disease specifically among WCBA.10 In particular, comprehensive long-term trend analyses and age–period–cohort (APC) evaluations in this population remain scarce, leaving important gaps in understanding temporal dynamics and generational patterns of HHD burden.

The GBD study serves as a critical tool for comprehensively assessing disease burdens, systematically quantifying health losses to inform evidence-based public health policymaking.11 The objective of our research is to examine the changes over time in the burden of HHD among WCBA globally, regionally, and nationally from 1992 through 2021, using data from GBD 2021. Multidimensional evaluations incorporating prevalence counts, prevalence rates, and DALYs will be conducted, with further exploration of geographic disparities, age-specific variations, and secular trends.

Methods

Data Source

We downloaded data from GBD 2021 in Global Health Data Exchange (https://ghdx.healthdata.org/), including prevalence, deaths and DALYs. We extracted data using the following settings: Cause = hypertensive heart disease; Measures = prevalence, deaths, and DALYs; Metrics = number and rate; Sex = female; Age = seven 5-year age groups (15–19 to 45–49 years); Locations = global, 21 GBD regions, and 204 countries and territories; Years = 1992–2021. The GBD 2021 included information regarding the disease burden associated with 371 illnesses across 21 GBD regions and 204 countries or territories.12 Original data sources include disease registries, health service contact data, vital registration systems and household surveys.13 The detailed methods used for the GBD 2021 have been described in the previous publications.12,14 In this study, the WHO defined WCBA as women aged 15–49 years.15

SDI

The SDI is a composite metric utilized in the GBD studies, reflecting the social advancement and economic circumstances that impact health results across various regions and nations/territories. It is calculated from national-level income per capita, educational level in people 15 years old and older, and fertility of women under 25 years of age.16 The SDI values range from 0 to 1, and the higher the SDI value, the better socio-economic development.

APC Analysis

The APC model was applied to HHD mortality (age-specific mortality rates) among WCBA. We selected mortality for APC modeling because mortality trends are more comparable across settings and less influenced by changes in case ascertainment than prevalence, while DALYs additionally depend on disability weights and modeling assumptions. The APC model is widely used in epidemiological studies.17 It independently evaluates age, period, and birth cohort effects on mortality rates.18 In this study, we obtained 7 age groups from the GBD dataset (15 to 19 years, 20 to 24, ……, 45 to 49) and periods into 5-year continuous intervals (1992 to 1996, 1997 to 2001, ……, 2017 to 2021). Based on the mathematical relationship between the three variables (age is equal to period minus birth cohort), we established 12 birth cohorts in this study.19 We acknowledge the identifiability issue inherent to APC models due to the collinearity among age, period, and cohort; therefore, estimable functions and standard constraints implemented in the NCI APC tool were used, and confidence intervals were derived from the APC model output. Model establishment is carried out at https://analysistools.cancer.gov/apc/, which was provided by National Cancer Institute.18 In the APC model, we used net drift and local drift to present total annual percentage change (%) and annual percentage change of age-specific mortality (%), respectively. Longitudinal age curve, period relative risk (RR), and cohort RR were used for showing age, period, and cohort effect, respectively.

Data Analysis

The data analysis and visualization were conducted using R software (version 4.4.1). The descriptive data are disaggregated by age, sex, location and SDI quintile. All data downloaded from GBD database are presented by estimated values and their 95% uncertainty intervals (UI). The 95% UI were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.20 The age-standardized rate was calculated with direct standardization method based on the global age distribution.21 All rates are reported per 100,000 population. Scatter plots were utilized to visualize the relationship between SDI and death/DALY rates, while the Wald χ2 test was reserved for testing significance within the mortality-based APC model.18 A p-value of less than 0.05 (two-sided) was considered statistically significant.

Results

Global Level

The global and regional numbers of prevalent cases, deaths, and corresponding prevalence and mortality are presented in Table 1 and Figures 1 and 2. From 1992 to 2021, the number of prevalent cases among WCBA increased by approximately 95.73%, reaching 544,545 (95% UI: 400,850 to 742,840) in 2021. This substantial rise in absolute case numbers occurred in the context of global population growth and should be interpreted separately from age-standardized prevalence rates. The percentage change in the number of HHD prevalence saw an upward trend across all SDI regions. In 2021, the prevalence of HHD among WCBA was recorded at 27.94 (95% UI: 20.57 to 38.12) per 100,000 individuals, marking an increase of 39.05% since 1992. Furthermore, the APC model estimated a global net drift of HHD mortality in WCBA at −0.87% (95% CI: −0.97% to −0.78%) per year, ranging from −1.29% (95% CI: −1.47% to −1.12%) in low SDI region to 1.43% (95% CI: 0.91% to 1.96%) in high SDI region. Apparently, only high SDI region displayed an increasing mortality trend.

Table 1.

The Prevalent Cases, Deaths, Prevalence and Mortality Rates of HHD in WCBA from 1992 to 2021 at the Global and Regional Levels

Prevalence Mortality
1992 2021 1992 2021
Cases Rate Cases Rate Cases Rate Cases Rate
Global 278207.44 (212,166.14, 364,566.55) 20.09 (15.32, 26.33) 544,544.9 (400,850.09, 742,840.06) 27.94 (20.57, 38.12) 20,711.29 (12,456.38, 25,865.24) 1.5 (0.9, 1.87) 25,669.09 (18,551.15, 30,045.34) 1.32 (0.95, 1.54)
High SDI 51754.73 (39,286.12, 68,412.31) 22.54 (17.11, 29.8) 71,910.15 (53,563.63, 94,227.94) 29.57 (22.03, 38.75) 1170.41 (1093.27, 1258.57) 0.51 (0.48, 0.55) 1940.5 (1640.7, 2158.01) 0.8 (0.67, 0.89)
High-middle SDI 39910.26 (30,650.93, 52,153.04) 13.98 (10.74, 18.27) 75,096.03 (55,032.07, 105,456.61) 24.61 (18.04, 34.56) 2256.15 (1857.14, 2749.3) 0.79 (0.65, 0.96) 1490.29 (1251.87, 1823.87) 0.49 (0.41, 0.6)
Middle SDI 97908.02 (75,941.82, 127,737.01) 21.07 (16.34, 27.49) 191,010.7 (140,556.17, 262,241.5) 30.88 (22.73, 42.4) 7625.68 (4681.54, 9087.27) 1.64 (1.01, 1.96) 7255.26 (5343.63, 8669.32) 1.17 (0.86, 1.4)
Low-middle SDI 62029.23 (47,279.12, 81,123.58) 21.7 (16.54, 28.38) 134,297.17 (98,867.69, 185,186.99) 26.53 (19.53, 36.58) 5664.51 (2658.47, 7872.94) 1.98 (0.93, 2.75) 8260.2 (5617.28, 10,103.75) 1.63 (1.11, 2)
Low SDI 26348.72 (18,930.28, 36,847.46) 22.4 (16.1, 31.34) 71,772.77 (50,590.24, 100,631.34) 26.16 (18.44, 36.69) 3973.64 (1554.15, 5504.66) 3.38 (1.32, 4.68) 6694.59 (3814.5, 8823.44) 2.44 (1.39, 3.22)
Andean Latin America 3230.25 (2475.9, 4123.01) 32.39 (24.82, 41.34) 6233.83 (4510.31, 8447.52) 35.72 (25.84, 48.4) 104.94 (84.67, 127.25) 1.05 (0.85, 1.28) 91.12 (68.66, 125.66) 0.52 (0.39, 0.72)
Australasia 257.38 (185.85, 347.08) 4.68 (3.38, 6.31) 413.13 (282.6, 597.87) 5.72 (3.91, 8.28) 6.72 (6.23, 7.25) 0.12 (0.11, 0.13) 6.29 (5.72, 6.86) 0.09 (0.08, 0.1)
Caribbean 2837.9 (2180.77, 3663.56) 29.53 (22.69, 38.12) 4872.77 (3562.76, 6701.7) 40.51 (29.62, 55.71) 172.15 (117.63, 232.87) 1.79 (1.22, 2.42) 285.65 (191.24, 411.04) 2.37 (1.59, 3.42)
Central Asia 1713.75 (1266.13, 2256.2) 9.95 (7.35, 13.1) 2782.39 (1991.29, 3803.63) 11.47 (8.21, 15.68) 168.25 (142.91, 191.72) 0.98 (0.83, 1.11) 217.9 (176.2, 278.39) 0.9 (0.73, 1.15)
Central Europe 3685.58 (2862.21, 4704.41) 11.84 (9.19, 15.11) 4247.9 (3132.56, 5622.2) 16.49 (12.16, 21.83) 275.24 (261.29, 297) 0.88 (0.84, 0.95) 205.67 (176.66, 234.73) 0.8 (0.69, 0.91)
Central Latin America 9031.56 (6927.6, 11,699.21) 20.38 (15.63, 26.4) 14,074.76 (10,001.39, 19,731.62) 20.64 (14.67, 28.93) 298.39 (285, 313.84) 0.67 (0.64, 0.71) 296.41 (229.46, 358.65) 0.43 (0.34, 0.53)
Central Sub-Saharan Africa 2722.12 (1747.51, 4239.45) 20.77 (13.33, 32.34) 7970.57 (5090.83, 12,401.71) 24.41 (15.59, 37.98) 490.05 (174.96, 774.5) 3.74 (1.33, 5.91) 1058.5 (494.52, 1682.7) 3.24 (1.51, 5.15)
East Asia 53025.53 (39,646.6, 71,316.04) 15.5 (11.59, 20.85) 98,553.76 (70,156.21, 140,847.7) 29.78 (21.2, 42.56) 4638.87 (2607.03, 5940.38) 1.36 (0.76, 1.74) 1841.76 (1117.21, 2953.1) 0.56 (0.34, 0.89)
Eastern Europe 2004.64 (1442.82, 2827.81) 3.62 (2.6, 5.1) 1394.73 (882.37, 2164.67) 2.89 (1.83, 4.49) 265.62 (255.23, 278.32) 0.48 (0.46, 0.5) 202.59 (170.62, 237.78) 0.42 (0.35, 0.49)
Eastern Sub-Saharan Africa 10911.03 (7362.75, 15,928.77) 23.81 (16.07, 34.76) 29,031.41 (19,409.53, 42,488.07) 27.11 (18.12, 39.67) 2179.02 (745.01, 2977.81) 4.76 (1.63, 6.5) 3024.33 (1593.15, 3989.88) 2.82 (1.49, 3.73)
High-income Asia Pacific 8677.16 (6374.83, 11,769.74) 18.95 (13.92, 25.71) 7380.01 (5193.86, 10,344.1) 19.4 (13.65, 27.19) 164.19 (132.38, 180.13) 0.36 (0.29, 0.39) 45.78 (41.1, 62.12) 0.12 (0.11, 0.16)
High-income North America 31869.42 (24,165.66, 42,454.05) 42.13 (31.94, 56.12) 42,901.87 (31,026.22, 56,925.24) 51.06 (36.93, 67.75) 610.68 (596.35, 627.08) 0.81 (0.79, 0.83) 1410.79 (1249.05, 1481.58) 1.68 (1.49, 1.76)
North Africa and Middle East 40027.53 (31,542.25, 50,998.91) 48.02 (37.84, 61.18) 93,982.99 (69,660.22, 126,576.63) 58.98 (43.72, 79.44) 2219.32 (1079.67, 3045.27) 2.66 (1.3, 3.65) 3252.03 (2153.33, 4222.98) 2.04 (1.35, 2.65)
Oceania 326.7 (246.55, 425.82) 19.84 (14.97, 25.86) 759.82 (545.74, 1061.9) 21.89 (15.72, 30.59) 58.78 (25.52, 99.95) 3.57 (1.55, 6.07) 108.39 (55.24, 169.95) 3.12 (1.59, 4.9)
South Asia 44670.02 (33,627.9, 60,510.1) 16.76 (12.62, 22.7) 105,079.26 (74,760.06, 151,428.31) 21.27 (15.13, 30.64) 3446.62 (1129.2, 5179.29) 1.29 (0.42, 1.94) 5615.68 (3552.02, 7557.47) 1.14 (0.72, 1.53)
Southeast Asia 27743.65 (21,575.69, 35,691.77) 22.02 (17.12, 28.33) 53,440.94 (39,969.17, 72,220.15) 29.17 (21.82, 39.42) 2520.36 (1265.45, 3374.75) 2 (1, 2.68) 3510.48 (2174.74, 4422.69) 1.92 (1.19, 2.41)
Southern Latin America 1906.36 (1393.62, 2489.88) 14.96 (10.94, 19.54) 3155.96 (2208.48, 4494.29) 18.11 (12.67, 25.79) 83.2 (77.36, 88.8) 0.65 (0.61, 0.7) 67.16 (62.45, 71.86) 0.39 (0.36, 0.41)
Southern Sub-Saharan Africa 2798.94 (1865.22, 4138.61) 19.85 (13.23, 29.35) 5969.76 (3884.84, 8953.28) 27.5 (17.89, 41.24) 634.64 (471.65, 745.83) 4.5 (3.34, 5.29) 858.53 (676.53, 1164.84) 3.95 (3.12, 5.36)
Tropical Latin America 11925.48 (9068.48, 15,644.85) 28.55 (21.71, 37.45) 19,686.53 (13,811.56, 28,260.96) 32.48 (22.79, 46.63) 673.49 (651.96, 697.22) 1.61 (1.56, 1.67) 615.41 (541.89, 651.45) 1.02 (0.89, 1.07)
Western Europe 7220.01 (5394.78, 9500.63) 7.5 (5.61, 9.87) 9695.46 (6973.08, 13,434.3) 10.41 (7.48, 14.42) 171.43 (164.21, 178.9) 0.18 (0.17, 0.19) 120.21 (115.28, 124.29) 0.13 (0.12, 0.13)
Western Sub-Saharan Africa 11622.43 (7955.98, 16,888.73) 25.03 (17.13, 36.37) 32,917.07 (22,032.74, 48,555.98) 27.46 (18.38, 40.5) 1529.32 (785.64, 2142.05) 3.29 (1.69, 4.61) 2834.4 (1401.41, 3839.63) 2.36 (1.17, 3.2)
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Notes: Data in parentheses represent 95% uncertainty intervals for prevalent cases, deaths, prevalence and mortality rates. Prevalence and mortality rates are expressed per 100,000 population.

Abbreviations: HHD, hypertensive heart disease; UI, uncertainty interval; WCBA, women of childbearing age.

Figure 1.

Figure 1

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The numbers (per thousand) of prevalent cases, deaths, DALYs of HHD in WCBA from 1992 to 2021.

Abbreviations: DALYs, disability-adjusted life years; HHD, hypertensive heart disease; WCBA, women of childbearing age.

Figure 2.

Figure 2

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Prevalence, mortality, DALY rate of HHD in WCBA from 1992 to 2021.

Abbreviations: DALYs, disability-adjusted life years; HHD, hypertensive heart disease; WCBA, women of childbearing age.

GBD Regional and National Level

When analyzed at the regional level, East Asia demonstrated the most pronounced increase in HHD prevalence between 1992 and 2021, rising from 15.50 (95% UI: 11.60 to 20.85) to 29.78 (95% UI: 21.20 to 42.56) per 100,000 population. In 2021, North Africa and the Middle East exhibited the highest prevalence rate globally, at 58.98 (95% UI: 43.72 to 79.44) per 100,000, followed by High-income North America (51.06; 95% UI: 36.93 to 67.75) and the Caribbean (40.51; 95% UI: 29.62 to 55.71), as shown in Figure 3A. These regions demonstrated substantially higher prevalence compared with most other global regions. Regarding disease burden, the most marked decline in DALY rates was observed in High-income Asia Pacific, decreasing from 19.67 (95% UI: 15.95 to 21.80) to 7.51 (95% UI: 6.49 to 9.70) during the study period (Figure 3B). In contrast, Southern Sub-Saharan Africa reported the highest DALY rate in 2021, reaching 193.30 (95% UI: 152.63 to 261.74) per 100,000, markedly exceeding other regions.

Figure 3.

Figure 3

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World map of prevalence (A) and DALY rate (B) of HHD in WCBA in 2021.

Abbreviations: DALYs, disability-adjusted life years; HHD, hypertensive heart disease; WCBA, women of childbearing age.

At the national level, prevalence increased in most countries (Supplementary Table 1). State of Kuwait demonstrated the most substantial relative increase, rising from 77.59 (95% UI: 59.77 to 99.27) to 104.28 (95% UI: 74.53 to 145.61), followed by United Arab Emirates (from 32.36 to 55.99 per 100,000). In 2021, State of Kuwait, Republic of Tunisia, and Hashemite Kingdom of Jordan recorded the highest national prevalence rates globally.

Global Trends by Age Group

Globally, HHD prevalence, mortality, and DALY rates in WCBA exhibited an increasing trend, with accelerated progression observed in older age groups (Supplementary Figures 1 and 2). In 2021, the prevalence was lowest in the 15–19 years group at 3.60 (95% UI: 2.14 to 5.79) and peaked in the 45–49 years group at 82.87 (95% UI: 53.66 to 121.15). A similar age-dependent pattern was observed for mortality, demonstrating the lowest values in the 15–19 years group at 0.17 (95% UI: 0.11 to 0.22) and the highest in the 45–49 years group at 4.81 (95% UI: 3.49 to 5.60). Table 2 presents prevalent cases, deaths, prevalence, and mortality of HHD among WCBA in 1992 and 2021, stratified by age group.

Table 2.

The Prevalent Cases, Deaths, Prevalence and Mortality Rates of HHD Across Age Groups from 1992 to 2021 at the Global Level

Prevalence Mortality
1992 2021 1992 2021
Cases Rate Cases Rate Cases Rate Cases Rate
15–19 years 7950.8 (5117.31, 11,756.01) 3.12 (2.01, 4.61) 10,917.65 (6498.82, 17,578.58) 3.6 (2.14, 5.79) 465.49 (240.49, 657.04) 0.18 (0.09, 0.26) 525.04 (341.52, 677.14) 0.17 (0.11, 0.22)
20–24 years 19862.64 (13,498.17, 27,851.29) 8.01 (5.45, 11.24) 27,541.17 (17,568.1, 41,778.66) 9.38 (5.98, 14.22) 683.83 (347.99, 957.03) 0.28 (0.14, 0.39) 713.58 (461.5, 909.89) 0.24 (0.16, 0.31)
25–29 years 29378.84 (18,907.58, 40,601.03) 12.67 (8.15, 17.51) 42,150.42 (25,930.16, 63,334.75) 14.49 (8.91, 21.77) 1176.85 (601.81, 1503.89) 0.51 (0.26, 0.65) 1176.78 (793.17, 1446.96) 0.4 (0.27, 0.5)
30–34 years 34786.13 (21,475.22, 51,834.18) 17.65 (10.9, 26.3) 62,036.53 (37,864.3, 93,928.43) 20.75 (12.67, 31.42) 1897.6 (1087.08, 2433.75) 0.96 (0.55, 1.23) 2179.77 (1566.01, 2570.03) 0.73 (0.52, 0.86)
35–39 years 43768.86 (27,169.96, 65,219.86) 24.17 (15, 36.01) 85,548.71 (49,657.96, 133,598.72) 30.79 (17.88, 48.09) 3119 (1789.81, 3929.73) 1.72 (0.99, 2.17) 3622.59 (2522.49, 4280.8) 1.3 (0.91, 1.54)
40–44 years 58754.59 (36,485.15, 89,442.93) 38.58 (23.95, 58.73) 121,061.72 (73,844.85, 193,799.25) 48.8 (29.77, 78.12) 5071.61 (3248.58, 6257.65) 3.33 (2.13, 4.11) 6109.34 (4403.49, 7241.23) 2.46 (1.77, 2.92)
45–49 years 83705.59 (56,386.48, 118,511.01) 70.14 (47.25, 99.3) 195,288.69 (126,446.02, 285,486.84) 82.87 (53.66, 121.15) 8296.91 (5399.77, 10,151.32) 6.95 (4.52, 8.51) 11,342 (8224.24, 13,200.33) 4.81 (3.49, 5.6)
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Notes: Data in parentheses represent 95% uncertainty intervals for prevalent cases, deaths, prevalence and mortality rates. Prevalence and mortality rates are expressed per 100,000 population.

Abbreviations: HHD, hypertensive heart disease; UI, uncertainty interval; WCBA, women of childbearing age.

Global Burden by SDI

Figure 4 presents the 2021 global burden of HHD among WCBA. Higher SDI regions generally exhibited lower DALY rates, while low-SDI regions demonstrated greater data point dispersion. In 2021, among the five SDI regions, high-middle SDI regions had the lowest mean prevalence at 24.61 (95% UI: 18.03 to 34.56), mean mortality at 0.49 (95% UI: 0.41 to 0.60), and mean DALY rate at 25.44 (95% UI: 21.59 to 31.05). In contrast, middle SDI regions showed the highest mean prevalence at 30.88 (95% UI: 22.73 to 42.40) and mean mortality at 1.17 (95% UI: 0.86 to 1.40), while low SDI regions exhibited the highest mean DALY rate at 125.39 (95% UI: 73.95 to 165.06).

Figure 4.

Figure 4

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Mortality (A) and DALY rate (B) of HHD in WCBA across five SDI regions in 2021.

Abbreviations: DALY, disability-adjusted life year; HHD, hypertensive heart disease; WCBA, women of childbearing age; SDI, Socio-demographic index.

Supplementary Figure 3 displays temporal trends in DALY rates and mortality across all SDI regions from 1992 to 2021. Both mortality and DALY rates generally exhibited a declining trend with increasing SDI. In African regions, including Central Sub-Saharan Africa, both mortality and DALY rates demonstrated a declining trend yet remained persistently elevated above the fitted curve. Among high-income regions, high-income North America showed a progressive increase in DALY and mortality rates, which substantially exceeded the fitted curve throughout the study period, whereas other high-income regions aligned closely and fell below the SDI-predicted curve. Except Southeast Asia, all Asian regions maintained DALY and mortality rates below the fitted curve across all years from 1992 to 2021. All regions in the Americas recorded DALY and mortality rates lower than the fitted curve, with Central Latin America displaying the lowest values among the four American regions.

APC Effects of the HHD

Figure 5 presents the estimates of age-period-cohort effects derived from the APC model categorized by five SDI regions. Age effects are depicted through longitudinal age curves that illustrate the natural history of HHD mortality associated with age. Period effects are represented as relative risks of mortality across various time intervals, utilized for monitoring progress over different years, while cohort effects reflect relative mortality risk by birth cohorts, allowing for tracking of mortality changes across these groups. Across the various SDI regions, similar trends in age effects were observed, with the highest mortality risk noted in individuals aged 45 to 49 years, and this risk increased with advancing age. In contrast, the lowest risk was identified among those aged 15 to 19 years, indicating improved survival rates within this demographic. When compared to other nations, countries with high-middle SDI reported a consistently lower mortality rate across all age brackets. Period effects indicated a reduction in mortality risk across five SDI regions during the study period, except in high SDI nations, suggesting an overall decline in mortality risk from 1992 to 2021. Countries with high-middle SDI exhibited the most significant decrease in period risks spanning from 1992 to 2021, with rates dropping from 1.26 (95% CI: 1.16 to 1.37) to 0.65 (95% CI: 0.60 to 0.71). On a global scale, a general reduction in risk was observed among younger populations. The cohort effects, akin to period effects, differed in high SDI nations compared to others. The other SDI groups exhibited declining cohort risks, with high-middle SDI countries demonstrating the most significant reduction, decreasing from 2.18 (95% CI: 2.00 to 2.38) to 0.53 (95% CI: 0.32 to 0.91).

Figure 5.

Figure 5

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The APC model on HHD mortality by five SDI regions in 2021. (A) Age effects (B) Period effects (C) Cohort effects.

Notes: The dots and shaded areas denote mortality rates or rate ratios and their corresponding 95% CIs; the horizontal dashed line (RR = 1.0) serves as the null reference for no effect; the vertical dashed line marks the reference year or birth cohort for comparative analysis.

Abbreviations: APC model, Age–period–cohort model; HHD, hypertensive heart disease; SDI, Socio-demographic Index.

Discussion

Leveraging the GBD 2021 database, this study provides the first comprehensive epidemiological characterization of HHD among WCBA worldwide from 1992 to 2021. The findings indicate increasing prevalence alongside declining mortality, highlighting persistent regional disparities and the need for context-specific prevention strategies.

The Lancet Commission’s Women and Cardiovascular Disease: A Call for Action to Achieve Equity by 20305 highlights the urgent need to address cardiovascular conditions accounting for 35% of global female mortality. Consistent with the clinical importance of cardiovascular disease, autopsy-based studies of sudden natural deaths have identified cardiovascular diseases as leading causes, with coronary artery disease and acute myocardial infarction most frequently observed.22 This imperative aligns with the United Nations Sustainable Development Goals (SDG 3.4) targeting a one-third reduction in premature deaths from non-communicable diseases by 2030. Notably, hypertension has emerged as the predominant cardiovascular risk factor, with a population-attributable fraction (PAF) of 22.3%.23 Furthermore, in WCBA, pregnancies complicated by HHD are associated with increased risks of preeclampsia, placental abruption, and intrauterine fetal death. These findings highlight the critical necessity of investigating the disease characteristics and etiological factors of HHD among WCBA worldwide, a goal that directly aligns with the purpose of this study.

Between 1992 and 2021, HHD among WCBA globally exhibited divergent epidemiological trends: declining mortality rates, and increased absolute case numbers and deaths. This pattern suggests that while advancements in clinical management have reduced individual mortality risks, population growth and expanding disease prevalence have paradoxically driven higher death counts. Notably, the highest number of deaths and DALYs rates were reported in low and middle SDI countries, which may be associated with their large population size and aligns with similar patterns observed for other diseases.24,25 Additionally, this may also be associated with poor dietary habits and environmental factors,26 as well as limited accessibility and acceptability of cardiovascular medications among this population.27 Although absolute numbers increased, age-standardized rates generally declined. This suggests that prevention and management strategies targeting HHD among women of reproductive age have achieved some success, although the disease burden remains substantial. Without substantial socioeconomic development, appropriate policies, and strong healthcare system support, the high disease burden among WCBA signifies significant productivity losses and greater pressure on health and long-term care systems, particularly in low-income countries.26,28 Therefore, addressing socioeconomic disparities and strengthening healthcare infrastructure are crucial steps to alleviate the global burden of these diseases.29 Systematic global HHD assessments provide essential evidence for policymakers and clinicians to develop targeted prevention frameworks and optimize WCBA-specific disease management protocols.

Distinct regional disparities characterize the evolving burden of HHD among WCBA. In high SDI countries, the transition toward urbanized lifestyles may be associated with increasing BMI and cardiometabolic risks. This shift is characterized by modifiable behavioral patterns such as smoking and poor diet, alongside physiological risk factors including hypertension and hypercholesterolemia, which may collectively contribute to adverse pregnancy outcomes and cardiovascular complications among women of childbearing age.30,31 In specific high-SDI nations such as the Netherlands and Ireland, improvements in healthcare infrastructure may be associated with more precise diagnostic detection and enhanced reporting practices, potentially contributing to higher recorded prevalence. Such increases may partly reflect earlier detection or potential overdiagnosis rather than true increases in disease burden. At the same time, greater therapeutic accessibility may have contributed to declining mortality rates, resulting in a pattern of increased prevalence alongside improved survival outcomes.32 Furthermore, in high SDI countries, the prevalence of HHD may be overestimated, as data are primarily collected from major urban centers, and more robust healthcare data systems may elevate reported prevalence rates.33 Therefore, mortality trends observed in regions with a high socio-economic development index should be interpreted with caution, as improvements in diagnostic, reporting, and surveillance practices may partially influence the observed patterns, rather than reflecting true epidemiological changes. Conversely, low and middle SDI countries demonstrate disproportionately high mortality rates and DALY burdens—exceeding or paralleling global averages—despite lower reported prevalence rates.34 This paradox may be related to systemic limitations in healthcare infrastructure and resource allocation. This highlights that national healthcare policymakers should prioritize primary care and primary prevention for HHD. For example, China, a middle SDI region, has launched the Healthy China 2030 initiative to improve overall population health and reduce disease prevalence and mortality.35 This study examines the relative impacts of age, period, and birth cohort effects on trends in the mortality of HHD among WCBA. Age effects demonstrated similar patterns across SDI regions, with increasing risks and distinct age-specific disease burdens. The prevalence rates remained relatively low in the 15–24 age group but increased progressively in the 25–34 and 35–49 age groups. This progression aligns with cumulative exposure to modern lifestyle-related risk factors, including sedentary behavior and high-salt diets.36 Furthermore, the risk of HHD is strongly associated with estrogen level fluctuations. With advancing age and progressive ovarian function decline, women experience significantly increased HHD risk.37 Globally, both adverse period effects and favorable cohort effects have been observed. On one hand, earlier-born cohorts were exposed to more risk factors, which may have contributed to elevated HHD risk. On the other hand, over the past three decades, chronic diseases have replaced acute and infectious diseases as major determinants of healthy life expectancy,38 which has been accompanied by growing global attention to chronic conditions such as HHD, and strategies for women’s health management have progressively improved. Consequently, compared with earlier-born individuals, later-born cohorts may experience higher-quality medical services and social security systems, which may be associated with reduced HHD risk. However, high SDI countries show an initial increase followed by subsequent decline, with cohort mortality peaking particularly between 1977 and 1992. Notably, while most global birth cohorts exhibited declining HHD-related mortality risks among WCBA, an increasing trend was observed in high SDI countries, particularly within the 1977–1992 birth cohorts. Accelerated urbanization may intensify work-related stress and chronic psychological strain among WCBA,39 which have been associated with increased hypertension risk. Concurrently, the proliferation of high-sugar, high-fat, and high-calorie dietary patterns has elevated obesity rates, with obesity, a major risk factor for HHD, which may contribute to greater disease burden.40 The disease risk trends between global and high-income populations underscore the multifactorial nature of HHD risk patterns, necessitating targeted prevention strategies informed by APC dynamics.

This study represents the comprehensive application of the APC model to analyze temporal trends in HHD prevalence among WCBA globally, regionally, and nationally. Distinct from prior GBD publications addressing hypertension or cardiovascular diseases broadly, our analysis specifically focuses on WCBA, offering novel epidemiological insights and policy-relevant evidence for this population. Consistent with the World Health Organization definition and previous GBD-based analyses, WCBA were defined as women aged 15–49 years and examined as a single analytic group.41 Nevertheless, we acknowledge that substantial heterogeneity exists across this age span—particularly between adolescents and women aged 40–49 years—which may reflect differing biological, reproductive, and cardiometabolic risk profiles. Despite these considerations, several limitations warrant further discussion. First, data quality hinges on nationally representative sources, with disparities in data collection protocols and diagnostic accuracy across countries due to demographic, economic, and infrastructural heterogeneity. Potential underdiagnosis and misclassification may persist, particularly in low-income countries with constrained data infrastructure. Second, the GBD database exhibits limited granularity regarding conditions unique to WCBA, such as gestational diabetes and preterm birth comorbidities. Furthermore, extensive statistical modeling applied to compensate for sparse primary data introduces substantial uncertainty intervals in HHD estimates for under-surveilled regions. As a result, regional and national comparisons—particularly those involving low-SDI settings—should be interpreted cautiously, since wider uncertainty intervals may reduce the robustness of rankings and between-region differences. In addition, although GBD estimates are derived from extensive statistical modeling, our APC results were based on these modeled point estimates, and we did not conduct additional sensitivity or robustness analyses under alternative APC specifications, which may affect the stability of the inferred age–period–cohort patterns. Third, while subnational variations within countries could refine trend interpretations, current analyses remain confined to national-level aggregates. Given the ecological nature of GBD data, caution is warranted when interpreting associations at the individual level, as ecological fallacy cannot be excluded. In addition, the absence of individual-level risk factor data limits our ability to directly assess the contribution of specific exposures to HHD risk among WCBA. Finally, inherent delays in GBD data updates may reduce the contemporaneity and practical relevance of findings, though standardized methodologies ensure cross-temporal comparability. Therefore, future databases must enhance data collection quality, particularly in low-SDI countries.

The current global landscape for prevention and control of chronic diseases like HHD among WCBA demands serious attention. To address this challenge, multi-level interventions should be implemented across social, policy, and healthcare domains. At the societal level, comprehensive cardiovascular health education should be strengthened, while enterprises should be encouraged to establish work environments conducive to cardiovascular wellbeing. From a policy perspective, governments must prioritize healthcare infrastructure improvement and enhance training for primary care providers to strengthen early HHD detection and intervention capabilities for WCBA. Within healthcare systems, institutions should advance research on HHD pathogenesis, risk factors, and disease progression patterns in WCBA. A multidisciplinary approach involving cardiology, obstetrics/gynecology, and endocrinology is essential to develop comprehensive, personalized treatment plans that address both cardiovascular management and reproductive/pregnancy-related health needs.

Conclusion

HHD represents a significant contributor to reduced healthy life expectancy among WCBA globally. APC analyses indicate overall unfavorable temporal patterns in the burden of HHD over the past three decades, with heterogeneous period effects across SDI settings, including a non-monotonic pattern in high-SDI countries. These findings highlight substantial and persistent disparities in HHD burden among WCBA across regions and countries and underscore the need for targeted prevention and management strategies and context-specific health policies.

Acknowledgments

The authors thank the Global Health Data Exchange for providing the data and AJE (www.aje.com) for language help.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data Sharing Statement

The data that support the findings of this study are derived from the Global Burden of Disease (GBD) and are publicly available at [https://vizhub.healthdata.org/gbd-results/].

Ethics Approval

This study used publicly available, de-identified data from the Global Burden of Disease (GBD) 2021 study. According to Article 32, Items 1 and 2, of the Measures for Ethical Review of Life Science and Medical Research Involving Human Subjects issued on February 18, 2023, in China, research using publicly available and anonymized data is exempt from ethical review. Therefore, ethical approval was not required. Written informed consent for participation was not required because no identifiable individual information was included in the analyses.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no competing interests in this work.

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Associated Data

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

Data Availability Statement

The data that support the findings of this study are derived from the Global Burden of Disease (GBD) and are publicly available at [https://vizhub.healthdata.org/gbd-results/].

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