Ischemic Heart Disease in the Middle East and North Africa, 1990–2021: An Integrated Analysis of Temporal Trends, Country‐Level Variation, SDI Patterns, and Risk Factors

ABSTRACT

Background

Ischemic heart disease (IHD) remains a leading cause of mortality and disability worldwide. Using Global Burden of Disease (GBD) 2021 estimates, this study provides an integrated assessment of IHD burden across the Middle East and North Africa (MENA) region from 1990 to 2021, highlighting temporal trends, inter‐country heterogeneity, sociodemographic index (SDI)‐related patterns, and attributable risk factors by sex and age.

Methods

We conducted a secondary analysis of GBD 2021 estimates for the 21 countries and territories in MENA. We assessed prevalence, deaths, and disability‐adjusted life years (DALYs), reporting counts and age‐standardized rates per 100,000 population with 95% uncertainty intervals (UIs). This framework allowed direct comparison of temporal change, cross‐country variation, development‐related gradients, and modifiable risk attribution within a single regional analysis.

Results

In 2021, the age‐standardized prevalence of IHD in MENA was 6404.8 per 100,000 (95% UI: 5872.0–7041.1), with an age‐standardized mortality rate of 202.8 (95% UI: 180.6–223.7) and DALY rate of 4023.2 (95% UI: 3581.7–4507.5). Although age‐standardized death and DALY rates declined from 1990 to 2021, the burden remained substantial and unevenly distributed. Kuwait had the highest age‐standardized prevalence [7806.4 (95% UI: 7141.6–8556.3)] and Turkey the lowest [5365.9 (95% UI: 4895.5–5874.7)]. Saudi Arabia had the largest increase in age‐standardized prevalence [17.1% (95% UI: 11.4–23.0)], whereas Turkey had the largest decrease [−11.9% (95% UI: −17.3 to −6.9)]. DALY rates increased progressively with age for both sexes, and IHD burden showed an inverse, non‐linear relationship with SDI. The leading contributors to IHD DALYs were elevated systolic blood pressure [49.6%], elevated LDL cholesterol [39.6%], and exposure to ambient particulate matter pollution [28.2%].

Conclusion

Despite reductions in age‐standardized mortality and DALY rates, IHD remains a major public health challenge in MENA, with substantial cross‐country variation and a large contribution from modifiable risks. By integrating temporal trends, inter‐country heterogeneity, SDI‐related patterns, and attributable risk factors, this study provides novel evidence for prioritizing prevention efforts across the region. These findings support context‐specific prevention strategies prioritizing hypertension control, lipid management, and improved access to cardiovascular prevention and treatment, alongside action to reduce air pollution exposure; implementation should be tailored to national risk profiles, disease trends, and health‐system capacity.

Abbreviations

ASR

age‐standardized rate

CODEm

cause of death ensemble model

CVD

cardiovascular disease

DALYs

disability‐adjusted life years

GBD

global burden of disease

HAQ

healthcare access and quality

IHD

ischemic heart disease

IHME

Institute for Health Metrics and Evaluation

LDL

low‐density lipoprotein

MENA

Middle East and North Africa

MI

myocardial infarction

SDI

sociodemographic index

SEV

summary exposure value

UIs

uncertainty Intervals

VA

verbal autopsy

VR

vital registration

YLDs

years lived with disability

YLLs

years of life lost

1. Background

Ischemic heart disease (IHD), commonly known as coronary artery disease (CAD), is a key clinical manifestation of atherosclerotic cardiovascular disease (CVD) and remains a major cause of death worldwide. CVDs continue to account for the largest share of deaths worldwide, and IHD may present clinically as myocardial infarction (MI), angina, or ischemic cardiomyopathy [1]. In addition, the prevalence of CVD nearly doubled between 1990 and 2019, with the number of affected individuals rising from 271 million to 523 million during this period [2]. As the most prevalent subtype of CVD, IHD affects an estimated 126 million individuals worldwide and causes about nine million deaths each year. It is more common in males than in females, with incidence typically beginning in early middle age and rising progressively over time [1].

The burden of CVDs is not uniformly distributed across the globe, with the effects of these diseases differing significantly from one region to another. This variation is largely influenced by an interplay of socioeconomic, demographic, and healthcare‐related factors, which can either exacerbate or mitigate the impact of CVDs [3]. In the Middle East and North Africa (MENA) region, CVDs are a leading cause of morbidity and mortality, significantly contributing to the healthcare burden [4, 5]. In 2019, IHD was responsible for around 2.55 million new cases in the region, highlighting the widespread nature of this condition. The age‐standardized incidence rate of IHD in MENA was 613.87 per 100,000, and it accounted for 11.01% of total disability‐adjusted life years (DALYs) [6].

The MENA region is characterized by a diverse population, encompassing both high‐income and low‐income nations. Rapid urbanization, economic development, and lifestyle changes have markedly influenced the region's health profile. The region contains countries with varying healthcare infrastructures, health policies, and prevalence of risk factors for CVDs [4, 7]. Studies indicate that the prevalence of CVDs and IHD in MENA is rising, driven by high rates of hypertension, diabetes, obesity, smoking, and sedentary lifestyles [8, 9, 10]. Furthermore, the demographic shift towards an aging population further exacerbates the risk and prevalence of CVDs [11]. The region exhibits a unique epidemiological pattern where traditional risk factors are compounded by genetic predispositions and socio‐cultural influences [12]. In the MENA region, those with CAD tend to be younger, and women, in particular, often experience a worse prognosis. Although the risk factors for CAD are very common, these factors are often not adequately recognized, treated, or controlled. Challenges in CAD care include low patient awareness, ineffective preventive measures, and limited access to recommended treatments [13].

Although the Global Burden of Disease (GBD) 2021 study provides standardized estimates of IHD burden, translating these estimates into regionally relevant evidence requires integrated analysis across epidemiological measures, demographic groups, development gradients, and attributable risks. Previous GBD‐based assessments of IHD in MENA have provided important evidence, but limited synthesis is available using the most recent GBD 2021 estimates to examine how country‐level trends, age‐ and sex‐specific patterns, SDI‐related variation, and modifiable risk factors together inform prevention priorities. The present study addresses this gap by providing an integrated comparative assessment of IHD prevalence, mortality, DALYs, and attributable risk factors across 21 MENA countries from 1990 to 2021. Unlike studies that report only regional totals or single epidemiological indicators, this analysis simultaneously examines temporal trends, inter‐country heterogeneity, SDI‐related patterns, and attributable risk factors to identify priority countries, populations, and modifiable risks for cardiovascular prevention and control in the region.

2. Methods

2.1. Overview

This secondary analysis was conducted in 2025 using publicly available, model‐derived GBD 2021 estimates. The GBD 2021 study, led by the Institute for Health Metrics and Evaluation (IHME), provides a comprehensive analysis of 371 illnesses and injuries and 88 risk factors spanning 204 countries, organized into 21 regions, covering the period 1990–2021. The MENA region comprises: Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Sudan, the Syrian Arab Republic, Tunisia, Turkey, the United Arab Emirates (UAE), and Yemen. All ages and both sexes were included. The core analytical workflow of this secondary analysis involved: (i) extracting age‐, sex‐, and year‐specific estimates of IHD prevalence, deaths, and DALYs from the GBD database; (ii) compiling data for the 21 countries within the MENA region; (iii) analyzing temporal trends from 1990 to 2021 using age‐standardized rates; (iv) evaluating inter‐country heterogeneity and SDI‐related patterns; and (v) assessing the proportion of the IHD burden attributable to selected risk factors using the GBD Comparative Risk Assessment framework. Previous research has thoroughly described the GBD methodologies and the advancements made since 2019 [14, 15]. Detailed information on the GBD methodology and data sources is available in prior GBD publications [14, 15] and through the GBD online tools: https://vizhub.healthdata.org/gbd-compare/ and http://ghdx.healthdata.org/gbd-results-tool. This study was reported in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

2.2. Case Definition and Data Sources

This section presents a succinct description of the GBD methodology as it pertains to IHD, with a comprehensive account of the GBD 2021 methods available in prior publications [14, 15]. IHD is classified into chronic IHD and acute MI. MI, as defined in the fourth universal definition, is identified by: (1) clinical confirmation of myocardial necrosis within a clinical context, (2) a change in cardiac biomarker levels accompanied by one of the following criteria: (i) symptoms indicative of cardiac ischemia, (ii) new or presumed new ST‐segment‐T wave abnormalities or the emergence of a left bundle branch block, (iii) confirmation of pathological Q waves on an electrocardiogram, (iv) imaging evidence of regional wall motion abnormalities or loss of viable myocardium, or (v) identification of a coronary artery thrombus via autopsy or angiography, or (3) sudden unexplained cardiac death, regardless of the presence or absence of a non‐coronary cause. The prevalent MI period extends for 28 days following the initial event, encompassing both the acute phase (0–2 days) and the subacute phase (3–28 days) [14, 15]. Chronic IHD is characterized by asymptomatic IHD after MI, survival beyond 28 days post‐MI onset, and a clinical diagnosis of stable exertional angina pectoris or definite angina pectoris. This diagnosis is determined through the Rose Angina Questionnaire (RAQ), a physician's assessment, or the use of nitrate medication for chest pain relief [14, 15].

The GBD 2021 estimates for IHD in the MENA region were derived from harmonized data compiled by the IHME. Fatal IHD estimates were based on the GBD cause‑of‑death database, which was informed primarily by national and subnational vital registration (VR) systems and verbal autopsy (VA) studies. VA sources were excluded if they did not meet World Health Organization standards, were restricted to populations younger than 30 years, or showed implausible patterns. Following quality assessment, poor‑quality VR data and ICD8/ICD9BTL data points from selected countries were also treated as outliers. Non‑fatal IHD estimates were derived from an integrated database comprising surveillance systems, population‑based surveys, and panel surveys, as well as inpatient hospital data, administrative claims, and a non‑fatal 30‑day MI database. Further details on the data sources used to calculate the GBD 2021 IHD burden are available in the GBD Data Input Sources database.

2.3. Mortality Estimation

The cause of death database was developed using data obtained from verbal autopsies and VR systems. As part of the global GBD 2021 cause‐of‐death framework, the exclusion criteria were as follows: (1) VA studies that did not conform to WHO requirements; (2) VA studies limited to individuals under 30 years of age; (3) non‐representative subnational verbal autopsies from several states in India, as well as data from Papua New Guinea and Nepal; (4) VA data from nations and subnational regions with access to high‐quality VR data; (5) ICD8 and ICD9BTL datapoints from Germany and Mauritius; and (6) VR data from certain states in India that experts report as being low quality [14].

Cause‐specific mortality due to IHD was modeled utilizing the standard Cause of Death Ensemble model (CODEm), retaining the same location‐level covariates as in GBD 2019, as outlined in the referenced article [14]. For GBD 2021, improvements were made by redistributing deaths attributed to hypertension and applying noise‐reduction methods to enhance prediction accuracy and reliability [14]. CoDCorrect was subsequently utilized to calculate the number of expected deaths from each cause for each sex‐age‐nation‐year group. Finally, to derive YLLs, we multiplied the death count within each age stratum by the corresponding remaining life expectancy, using the GBD standard life table [14].

2.4. Morbidity Estimation

To revise the GBD 2021 MI database, a thorough systematic review was conducted [15]. This process incorporated data from inpatient claims, inpatient hospital records, and relevant literature to develop a comprehensive non‐fatal database for MI [15]. The 30‐day case fatality rate for acute MI was drawn from the literature and registries and then converted into an excess mortality rate. To harmonize incidence data from studies with differing MI definitions, the study utilized MR‐BRT, a robust meta‐regression tool [15]. Incidence and mortality data were age‐split for age ranges above 25 years, using a model based on established age patterns from the literature [15].

In GBD 2021, a systematic review was not undertaken for asymptomatic IHD following MI [15]. The model relies primarily on 28‐day survivors derived from excess mortality estimates within the MI framework. To refine survival estimates post‐MI, GBD integrated data on excess mortality and the standardized mortality ratio [15]. Furthermore, there have been no systematic reviews for angina since 2013. To estimate angina prevalence, IHME utilized United States claims data, the World Health Study surveys, and the National Health and Nutrition Examination Survey [15].

2.5. Modeling Strategy, Severity, and Years Lived With Disability

Customized estimates of cause‐specific mortality were produced from cause‐of‐death data, following the redistribution of garbage codes, to differentiate more clearly between acute and chronic IHD. Global proportions were applied to post‐CoDCorrect IHD deaths to derive MI death rates [15]. Utilizing these mortality estimates, as well as the incidence and excess mortality data, a DisMod model was used to calculate MI incidence and prevalence. These estimates were then divided into two periods, Days 1–2 and Days 3–28 post‐event, with separate disability weights assigned to each period. The disability weights were set at 0.432 for acute MI (Days 1–2) and 0.074 for subacute MI (Days 3–28) (Supporting Information S6: Table S1). A prior remission value of 1 month and a cap on the maximum excess mortality rate were implemented. The Healthcare Access and Quality (HAQ) Index and the age‐standardized summary exposure value (SEV) scalar for IHD served as covariates, with an inverse relationship imposed for HAQ [15]. Excess mortality data informed the prevalence of chronic IHD following MI, encompassing angina and heart failure. Adjustments were made to eliminate double counting, with remission set at 0. Angina prevalence and incidence were estimated using US claims data and data from the literature, and were further refined using MR‐BRT. Severity levels were determined utilizing the Medical Expenditure Panel Survey (MEPS), and fixed‐effect country‐level covariates were incorporated for mortality and prevalence. Angina severity was classified as mild, with a disability weight of 0.033; moderate (0.08); and severe (0.167) (Supporting Information S6: Table S1).

2.6. Compilation of Results

To determine YLLs, the number of deaths in each age range was multiplied by the remaining life expectancy for that age range, as specified in the GBD standard life table. The YLLs were combined with the YLDs to estimate the number of DALYs.

This research included risk factors classified in the GBD comparative risk assessment framework as having sufficient evidence of a causal association with IHD [16]. We also report the percentage of DALYs attributable to each risk factor, including elevated systolic blood pressure, elevated low‐density lipoprotein (LDL) cholesterol levels, ambient particulate matter pollution, smoking, and diets low in whole grains, omega‐6 fatty acids, nuts and seeds, fruit, omega‐3 fatty acids, vegetables, legumes, and fiber. Additional factors included kidney dysfunction, household air pollution, high body mass index, high fasting plasma glucose, low and high temperatures, second‐hand smoke, physical inactivity, and diets high in sodium, red meat, trans fatty acids, processed meat, and sugar‐sweetened beverages [16]. The risk factors and their relative risks have been documented elsewhere [16].

Summary rates were age‐standardized, whereas age‐specific rates were reported by age group and sex. All estimates were presented with 95% uncertainty intervals (UIs). Smoothing splines were used to analyze the relationship between the burden of IHD and SDI [17]. SDI is a comprehensive measure of socioeconomic development, incorporating mean income per capita, mean years of education (aged 15+), and the total fertility rate for women younger than 25. The SDI scale spans from 0 (least development) to 1 (highest development). R software (version 3.5.2) was used for all analyzes, including data tabulation and figure generation. All analyzes by country, sex, age group, and SDI were prespecified descriptive analyzes. No additional null‐hypothesis significance tests were performed; therefore, no p values or significance thresholds are reported. Because GBD estimates are model‐based outputs rather than direct tabulations from a single dataset, conventional numerators and denominators were not available for all reported proportions. Attributable fractions for individual risk factors were interpreted separately because they may overlap and should not be summed to estimate the total preventable burden. This study was reported in accordance with the GATHER guidelines to support transparent reporting of global health estimates.

2.7. Model Assumptions and Potential Biases

The present analysis used model‐derived GBD 2021 estimates rather than primary individual‐level data. These estimates depend on several assumptions, including the quality and representativeness of input data sources, the redistribution of ill‐defined or garbage‐coded deaths, the use of covariates to borrow strength across locations and years, and the generalizability of relative risks used in the comparative risk assessment framework. In countries with limited VR, surveillance, or hospital data, estimates may be more dependent on statistical modeling and therefore subject to wider uncertainty. Attributable fractions should also be interpreted separately because risk factors may overlap and share causal pathways. Consequently, the findings should be interpreted as descriptive and comparative estimates for priority‐setting rather than as direct causal evidence for specific countries or subpopulations.

3. Results

3.1. MENA Region

In 2021, IHD remained a major contributor to the disease burden in the MENA region, with an estimated 28,353,618 prevalent cases, 769,135 deaths, and 18,148,598 DALYs. The age‑standardized prevalence rate was 6404.8 per 100,000 population (95% UI: 5872.0–7041.1) and changed little between 1990 and 2021. By contrast, age‑standardized mortality and DALY rates declined by 26.3% and 30.2%, respectively, between 1990 and 2021 (Table 1; Supporting Information S7–S9: Tables [Link], [Link], [Link]).

Table 1.

Prevalence, deaths and DALYs due to ischemic heart disease in 2021, and the percentage change in age‐standardized rates from 1990 to 2021 (generated from data available from http://ghdx.healthdata.org/gbd-results-tool).

	Prevalence (95% UI)			Deaths (95% UI)			DALY (95% UI)
	Counts (2021)	ASRs (2021)	Pcs in ASRs 1990–2021	Counts (2021)	ASRs (2021)	Pcs in ASRs 1990–2021	Counts (2021)	ASRs (2021)	Pcs in ASRs 1990–2021
Middle East and North Africa	28,353,618 (25,902,216, 31,330,582)	6404.8 (5872, 7041.1)	−0.5 (−4.2, 3.3)	769,135 (685,360, 858,253)	202.8 (180.6, 223.7)	−26.3 (−32.6, −19.3)	18,148,598 (16,140,157, 20,526,103)	4023.2 (3581.7, 4507.5)	−30.2 (−37.1, −22.7)
Afghanistan	584,028 (535,534, 639,114)	6317.6 (5785.3, 6886.8)	−7.5 (−12.7, −2.5)	23,705 (18,124, 29,908)	280 (221.4, 346.2)	−22.5 (−39.2, −2.2)	685,745 (510,801, 895,881)	6178.3 (4747.6, 7813.3)	−26.2 (−43.6, −4.1)
Algeria	2,184,384 (1,996,826, 2,394,663)	6265.9 (5756, 6836.7)	−7.0 (−11.7, −2)	52,898 (42,964, 63,610)	212 (172.7, 251.7)	−31.7 (−42.5, −19.4)	1,081,869 (873,890, 1,320,138)	3452 (2807, 4159.9)	−37.1 (−48.1, −23.9)
Bahrain	66,751 (59,153, 74,791)	7066 (6420.8, 7782.3)	−2.0 (−7.9, 4.2)	831 (706, 958)	161.6 (140.6, 184.4)	−60.4 (−65.2, −54.8)	22,927 (19,536, 26,637)	2796.6 (2418.6, 3179.5)	−63.6 (−68.7, −58.2)
Egypt	4,274,327 (3,925,681, 4,666,757)	7100.3 (6580.9, 7664.2)	11.1 (5.6, 16.3)	161,697 (135,633, 190,625)	347.7 (297.3, 402.1)	−8.3 (−23.2, 9)	4,247,264 (3,552,704, 5,000,935)	6924.8 (5844.9, 8119.2)	−8.9 (−25.1, 8.7)
Iran	4,787,279 (4,042,187, 5,701,615)	6327.2 (5393.2, 7502)	−2.6 (−7.1, 2.4)	98,298 (88,892, 105,322)	146.1 (130.7, 157)	−43.8 (−47.1, −40.1)	2,059,628 (1,916,237, 2,206,642)	2731.3 (2517.3, 2920.9)	−47.1 (−50.1, −43.6)
Iraq	1,657,453 (1,525,969, 1,824,407)	7185.5 (6654.6, 7885)	4.1 (−0.5, 10.2)	47,232 (37,101, 56,094)	254.8 (204.2, 296.7)	2.1 (−20.7, 26.6)	1,119,623 (867,515, 1,361,252)	4905.3 (3858.3, 5827.7)	−11.2 (−33.1, 13.3)
Jordan	502,059 (455,336, 559,953)	6817 (6205, 7546.4)	2.3 (−3, 7.3)	5682 (4651, 6939)	98.3 (80.7, 117.7)	−50.7 (−60.5, −38.8)	145,876 (119,698, 179,501)	1947.2 (1603.4, 2349.6)	−53.9 (−63.6, −42.3)
Kuwait	229,758 (207,387, 253,908)	7806.4 (7141.6, 8556.3)	0.9 (−3.9, 5.7)	2885 (2385, 3473)	109.1 (90.4, 131.4)	−45.0 (−54.3, −34.7)	79,997 (66,368, 96,589)	2299.4 (1917, 2762.5)	−46.5 (−56, −35.8)
Lebanon	410,574 (377,768, 447,702)	6814.6 (6242.7, 7463)	7.5 (1.7, 12.5)	6045 (5086, 7076)	92.1 (77.7, 108)	−60.9 (−68.7, −51.3)	107,890 (92,700, 125,657)	1735.3 (1488.4, 2027.4)	−64.7 (−72, −55.5)
Libya	335,569 (303,899, 370,593)	6634.7 (6059.2, 7303)	4.8 (−0.2, 10.3)	8163 (6373, 10,500)	178.5 (140.3, 228.1)	10.1 (−15.2, 46.2)	207,948 (160,414, 267,731)	3765.5 (2952.8, 4839.1)	9.5 (−16.5, 48)
Morocco	2,312,028 (2,120,993, 2,510,177)	6850.4 (6335.8, 7416.4)	2.6 (−1.7, 7)	78,696 (61,239, 92,878)	267.2 (210.8, 310.9)	−9.8 (−27.5, 4.8)	1,736,792 (1,312,915, 2,080,879)	5211.8 (3980.8, 6188.4)	−17.5 (−35.6, −2.3)
Oman	138,192 (124,248, 152,420)	6854.9 (6259, 7535.7)	8.6 (2.2, 14.7)	2590 (2150, 3129)	179.3 (150.3, 211.7)	−40.5 (−54.7, −21)	67,718 (55,409, 82,265)	3393.7 (2837, 4065.1)	−47.7 (−61.2, −29.2)
Palestine	155,781 (141,746, 172,360)	6302.6 (5748.3, 6947.2)	2.4 (−3.1, 7.9)	3547 (3085, 3981)	188.7 (162.7, 211.7)	−34.7 (−46.8, −19.9)	83,101 (71,973, 93,812)	3458.7 (3014.4, 3871.8)	−37.5 (−50.6, −20.8)
Qatar	77,595 (69,086, 87,350)	7143.8 (6501, 7864.4)	−3.2 (−8.4, 1.9)	653 (499, 826)	123.2 (97.9, 147.9)	−68.0 (−75.1, −60.3)	20,662 (15,897, 26,147)	2139.5 (1690.4, 2627.2)	−69.6 (−76.7, −61.4)
Saudi Arabia	1,407,289 (1,272,029, 1,545,986)	7341.6 (6747.5, 7966.8)	17.1 (11.4, 23)	32,330 (26,304, 39,774)	185.9 (158.1, 219.1)	−17.6 (−36.3, 14)	1,075,689 (851,631, 1,338,613)	4219.8 (3530.6, 5082.9)	−13.7 (−35.1, 22.5)
Sudan	1,286,113 (1,180,803, 1,402,645)	6817.6 (6291, 7433.7)	2.6 (−2.9, 7.7)	42,892 (33,157, 56,641)	255.9 (202.4, 330.7)	−24.6 (−40.6, −2.8)	1,101,292 (809,661, 1,493,701)	5338.3 (4083.7, 7066.9)	−29.6 (−46.2, −5.8)
Syrian Arab Republic	888,454 (815,279, 977,048)	6859.5 (6321.6, 7467.6)	2.3 (−2.6, 7.1)	35,508 (27,709, 45,179)	353 (281.6, 432)	−4.8 (−27.6, 26.5)	833,291 (640,325, 1,088,802)	6688.8 (5230.4, 8518.9)	−15.2 (−38.2, 17.4)
Tunisia	793,610 (725,568, 870,100)	6011.9 (5516.8, 6558.8)	2.0 (−2.8, 7)	19,263 (14,374, 25,409)	163.6 (121.8, 215.7)	−25.0 (−42.5, −2.2)	388,556 (288,610, 522,602)	3036.7 (2267.1, 4065.1)	−27.3 (−45.3, −2.4)
Turkey	5,015,695 (4,562,045, 5,507,294)	5365.9 (4895.5, 5874.7)	−11.9 (−17.3, −6.9)	112,055 (92,077, 131,674)	133.4 (109.9, 155.9)	−34.8 (−46.4, −21.8)	2,187,119 (1,808,029, 2,591,481)	2419.3 (2008.1, 2857)	−43.1 (−53.7, −31.4)
United Arab Emirates	384,628 (344,256, 428,314)	7608.9 (6995.2, 8286)	4.6 (0.1, 9.4)	2885 (2296, 3515)	167.7 (136.6, 196.3)	−37.2 (−46, −26.2)	93,693 (74,473, 114,450)	2923.7 (2395.6, 3422)	−47.6 (−55.7, −37.3)
Yemen	835,602 (768,056, 915,424)	6182.8 (5696.1, 6755.9)	−1.4 (−6.1, 3.2)	30,562 (22,982, 39,981)	263.5 (201.8, 344.2)	−17.7 (−36.7, 7.7)	784,992 (575,647, 1,035,620)	5442.6 (4100.2, 7104.9)	−23.6 (−42.6, 3.1)

Abbreviations: ASRs, Age‐standardized rates; Pcs, Percentage changes

3.2. Country Level

Substantial heterogeneity was observed across countries. In 2021, age‑standardized prevalence ranged from 5365.9 per 100,000 in Turkey to 7806.4 per 100,000 in Kuwait. The lowest prevalence rates were observed in Turkey and Tunisia, whereas Kuwait and the UAE recorded the highest rates (Figure 1A; Supporting Information S7: Table S2).

Figure 1.

Age‐standardized prevalence (A), mortality rate (B), and DALY rate (C) for ischemic heart disease per 100,000 population in the MENA region in 2021, by sex and country.

Age‑standardized mortality rates showed even greater variation, ranging from 92.1 per 100,000 in Lebanon to 353.0 per 100,000 in the Syrian Arab Republic. Egypt and the Syrian Arab Republic recorded the highest mortality rates, while Lebanon and Jordan had the lowest (Figure 1B; Table S3). A similar pattern was observed for DALYs, with age‑standardized rates ranging from 1735.3 per 100,000 in Lebanon to 6924.8 per 100,000 in Egypt. The highest DALY rates were observed in Egypt and the Syrian Arab Republic, whereas Lebanon and Jordan had the lowest (Figure 1C; Table S4). Temporal trends also differed across countries. While the overall regional prevalence changed little between 1990 and 2021, age‑standardized prevalence declined in three countries and increased in five. Turkey experienced the largest decline (−11.9%), whereas Saudi Arabia recorded the largest increase (+17.1%). In contrast, age‑standardized mortality and DALY rates declined in most countries, with Qatar showing the largest reductions in both mortality (−68.0%) and DALY rates (−69.6%) (Supporting Information S7–S9: Tables [Link], [Link], [Link]; Supporting Information S1–S3: Figures [Link], [Link], [Link]).

3.3. Sex and Age Trends

In 2021, the number of prevalent IHD cases increased with age in both sexes, peaking in the 65–69 age range before declining at older ages; age‐specific prevalence rates also increased with age across most age groups (Figure 2A). In 2021, the number of female deaths peaked in the 80–84 age range before declining. Among males, the number of deaths peaked in the 65–69 age range before declining. The death rate rose with age in both sexes (Figure 2B). The number of DALYs rose with age in females to the 65–69 age range, and then declined with age. For males, it increased up to the 60–64 age range and then decreased. For both sexes, the DALY rates increased with age (Figure 2C). Across prevalence, deaths, and DALYs, both counts and rates were generally higher among males than females across age groups (Figure 2A–C).

Figure 2.

Number of prevalent cases and prevalence rate (A), number of deaths and mortality rate (B), and number of DALYs and DALY rate (C) for ischemic heart disease in the MENA region, by age group and sex, in 2021; rates are expressed per 100,000 population; dotted and dashed lines indicate the upper and lower 95% uncertainty intervals, respectively.

In 2021, age‐specific DALY rates in MENA exceeded corresponding global rates for both sexes across almost all age groups. The highest MENA/global DALY ratio was 2.7, observed in males aged 15–19 years. Compared with 1990, the MENA/global DALY ratio in 2021 was lower across most age ranges in both sexes, except among those aged 75 years and older (Figure 3).

Figure 3.

Ratio of the age‐specific DALY rate in the MENA region to the corresponding global DALY rate for ischemic heart disease, by age group and sex, from 1990 to 2021.

3.4. Association With the SDI

From 1990 to 2021, the age‐standardized DALY rate for IHD declined as the SDI rose, up to an SDI of 0.6. A slight increase was then observed to an SDI of around 0.65, followed by a decrease at higher SDI levels. The burden in Egypt was higher than expected during this period, whereas Turkey, Lebanon, Jordan, and Tunisia had lower‐than‐expected burdens (Figure 4).

Figure 4.

Age‐standardized DALY rates for ischemic heart disease across 21 countries and territories in the MENA region from 1990 to 2021, plotted against sociodemographic index (SDI); the black line indicates expected values based on the SDI‐burden relationship across all locations, and each point represents the observed age‐standardized DALY rate for one country or territory.

3.5. IHD Risk Factors

The percentage of IHD DALYs linked to specific risk factors differed across MENA countries. Regionally, the primary contributors were elevated systolic blood pressure (49.6%), elevated LDL cholesterol (39.6%), and exposure to ambient particulate matter pollution (28.2%), followed by high body mass index (22.4%) and smoking (20.5%) (Figure 5). These same three leading risks were observed in both males and females (Supporting Information S4 and S5: Figures S4 and S5).

Figure 5.

Percentage of IHD DALYs attributable to selected risk factors in countries of the MENA region in 2021. DALY, disability‐adjusted life year; IHD, ischemic heart disease.

4. Discussion

This study provides an integrated view of IHD burden in the MENA region by combining temporal trends, inter‐country variation, SDI‐related patterns, and attributable risk profiles. Compared with previous GBD‐based analyzes of IHD in MENA that covered data through 2019 [6], the present study extends the evidence base to GBD 2021 and confirms the persistently high regional burden of IHD despite declining age‐standardized mortality and DALY rates. By analysing these dimensions within a single framework, this study identifies priority countries and modifiable exposures more directly than earlier regional summaries. The results show that IHD remains a major and unevenly distributed cause of disease burden across the MENA region. Between 1990 and 2021, age‐standardized mortality and DALY rates declined, but age‐standardized prevalence changed little, indicating that a large population continues to live with IHD even as fatal outcomes have improved. This divergence between stable prevalence and declining mortality may reflect improved survival after acute events, better secondary prevention, population aging, or changes in case detection; however, the present descriptive analysis cannot determine the relative contribution of these mechanisms. This pattern is consistent with the global epidemiological transition, where advancements in acute cardiac care and the availability of basic secondary prevention medications have successfully reduced case‐fatality rates, but have occurred in the absence of effective primary prevention, resulting in a growing pool of chronic IHD survivors. The burden was generally higher among males and older adults, with a notable male predominance in early‐ and mid‐adulthood that narrows in the oldest age cohorts, reflecting the post‐menopausal convergence of cardiovascular risk in women. Furthermore, the elevated premature disease burden in younger cohorts remains a distinct regional characteristic, although the narrowing of the MENA/global DALY ratio since 1990 suggests relative improvement in some age groups. The mechanisms underlying this change cannot be determined from these data alone. Country‐level patterns showed substantial heterogeneity. The findings also identify a clear hierarchy of modifiable drivers, led by elevated systolic blood pressure, elevated LDL cholesterol, ambient particulate matter pollution, high body mass index, and smoking.

Country‐level findings indicate marked variation in IHD burden and trends across the region. These country‐level differences are particularly important because they reveal heterogeneity that would be obscured by regional averages alone. The highest age‐standardized prevalence estimates were observed in Kuwait, the UAE, Saudi Arabia, Iraq, and Qatar, while Saudi Arabia, Egypt, and Oman showed the largest increases over time. Conversely, Turkey, Afghanistan, and Algeria showed the largest declines in age‐standardized prevalence. These geographic disparities reflect a complex interplay of socioeconomic development, political stability, and health system configuration. For instance, the high mortality and DALY rates in Egypt and the Syrian Arab Republic contrast with the lower rates in Lebanon and Jordan. In Egypt, the high burden may reflect the combined influence of cardiometabolic risk, primary care capacity, and broader health‐system factors, although country‐specific causal mechanisms require further study. In Syria, the high burden may reflect the combined influence of cardiometabolic risk, health‐system disruption, reduced access to continuous care, and data‐related factors, although the present analysis cannot determine the contribution of each mechanism. Conversely, the lower‐than‐expected burden in Turkey and Jordan may reflect differences in risk‐factor profiles, access to care, health‐system organization, coding practices, or input data availability [18]. These patterns suggest that countries with persistently high or rising burdens may require more intensive surveillance, early detection, and long‐term management of cardiometabolic risk. These findings are broadly consistent with regional evidence showing high levels of cardiometabolic risk, including hypertension and dyslipidaemia, among cardiovascular patients in the Middle East.

The non‐linear relationship between the age‐standardized DALY rate and SDI also reflects a transitional phase. As countries move from low‐ to middle‐development status, changes in occupational structures, urbanization, and dietary shifts accelerate metabolic risk exposure before national health systems establish effective primary prevention and management protocols. Once development crosses the 0.65 SDI threshold, the burden declines, likely due to stronger public health infrastructures and pharmaceutical access. Deviations from this curve, such as Egypt's higher‐than‐expected burden, suggest that national health policies, primary care capacity, and cultural dietary patterns can modify the expected burden predicted by socioeconomic development alone.

4.1. Priority Drivers of IHD Burden in the MENA Region

The present findings indicate that IHD burden in the MENA region is primarily driven by a small number of modifiable cardiometabolic, environmental, and behavioral risk factors. Elevated systolic blood pressure was the leading contributor, followed by elevated LDL cholesterol, ambient particulate matter pollution, high body mass index, and smoking. This integrated attribution analysis is one of the key strengths of the study because it links temporal and geographic differences in burden to the modifiable exposures most likely to yield prevention gains. The discussion below therefore prioritizes these drivers according to their estimated contribution to IHD DALYs. Non‐modifiable characteristics, such as age, sex, ethnicity, and family history, remain important for individual risk stratification but are not the main focus of population‐level prevention in this analysis [18].

Elevated systolic blood pressure was the most important driver of IHD burden in the MENA region, accounting for 49.6% of IHD DALYs. This finding highlights hypertension prevention, detection, treatment, and long‐term control as the highest‐priority intervention area for reducing IHD burden. Despite the availability of effective therapies, blood pressure control remains suboptimal in many settings, reflecting gaps in awareness, treatment access, medication adherence, and continuity of care [19]. Strengthening population‐level screening, affordable access to antihypertensive treatment, guideline‐based primary care, and long‐term adherence programs could therefore produce substantial reductions in IHD morbidity and mortality across the region [20, 21].

Regional evidence supports this priority. Hypertension and pre‐hypertension are common across the Middle East, and previous pooled analyzes have shown substantial gaps in awareness, treatment, and control [22]. These gaps are particularly important because hypertension is highly prevalent, clinically detectable, and treatable, making it one of the most actionable targets for IHD prevention in MENA. When compared with the previous GBD cycles, the persistent dominance of elevated systolic blood pressure confirms that traditional cardiovascular risk factors have not been offset by recent clinical initiatives, reinforcing the need for structural interventions such as mandatory salt reduction in processed foods.

High LDL cholesterol was the second‐largest contributor to IHD burden in this study, accounting for 39.6% of IHD DALYs. This finding underscores the importance of lipid screening, early identification of high‐risk individuals, and improved access to effective lipid‐lowering therapy. Because LDL cholesterol is causally linked to atherosclerotic CVD and can be substantially reduced through statins and other evidence‐based therapies, improving lipid management represents a major opportunity to reduce IHD burden in the region [23, 24].

The high contribution of LDL cholesterol may reflect the combined effects of dietary change, obesity, diabetes, and insufficient diagnosis or treatment of dyslipidaemia in parts of the region [24, 25]. Although other lipid abnormalities may contribute to cardiovascular risk, LDL cholesterol should remain a central focus of IHD prevention. Wider lipid screening, risk‐based treatment, improved statin availability, and stronger secondary prevention after MI are therefore key priorities for MENA health systems. The high burden attributable to LDL cholesterol in this study is consistent with regional cohort studies showing that dyslipidaemia often goes undetected until the first clinical presentation of MI, highlighting a failure in opportunistic screening at the primary care level.

Ambient particulate matter pollution was the third‐largest contributor to IHD burden, accounting for 28.2% of IHD DALYs. Unlike hypertension and dyslipidaemia, this driver cannot be addressed solely through individual‐level clinical care. Its large contribution indicates that cardiovascular prevention in MENA requires multisectoral action, including air‐quality regulation, cleaner transport and energy policies, industrial emission control, and urban planning strategies that reduce population exposure to PM2.5 [26]. Given the high background levels of particulate matter reported in several MENA countries, reducing air pollution should be considered a major component of regional IHD prevention policy. This finding is particularly noteworthy when compared with other global regions. In MENA, natural dust and desert storms combine with anthropogenic emissions from rapid urbanization and petrochemical industries, creating a unique environmental profile. Consequently, the cardiovascular impact of PM2.5 in MENA is more pronounced than in regions with similar socioeconomic profiles, acting as an unavoidable, population‐wide exposure that amplifies underlying cardiometabolic vulnerability [26].

High body mass index accounted for 22.4% of IHD DALYs, making excess adiposity another important but secondary driver relative to blood pressure, LDL cholesterol, and air pollution. Its effect on IHD is likely mediated through multiple pathways, including hypertension, dyslipidaemia, insulin resistance, and diabetes. Therefore, obesity prevention and management should be integrated with broader cardiometabolic risk‐reduction strategies rather than considered in isolation. Population‐level measures promoting healthy diets, physical activity, and healthier food environments, together with clinical approaches for high‐risk individuals, could reduce several interconnected drivers of IHD simultaneously [27].

The high prevalence of overweight and obesity in several MENA countries, particularly in the Gulf region, reinforces the need for prevention strategies beginning early in life and continuing through adulthood. However, in the context of the present findings, obesity is best interpreted as both a direct contributor to IHD and an upstream amplifier of other high‐impact risks, especially hypertension, dyslipidaemia, and diabetes [28, 29, 30].

Regional meta‐analytic evidence shows that overweight and obesity are highly prevalent in the Middle East, with substantial between‐country variation. These patterns are broadly consistent with the high IHD prevalence observed in several countries with elevated cardiometabolic risk profiles [10].

Childhood and adolescent obesity are particularly important because early‐life adiposity may accelerate the development of cardiometabolic risk factors and contribute to earlier IHD onset. This supports the need for school‐ and community‐based interventions targeting diet, physical activity, and sedentary behavior [31].

Smoking accounted for 20.5% of IHD DALYs, confirming its continued importance as a preventable behavioral driver of IHD in the MENA region. Although its estimated contribution was lower than that of elevated systolic blood pressure, elevated LDL cholesterol, and ambient particulate matter pollution, tobacco control remains highly cost‐effective and can reduce IHD risk within a relatively short period after cessation. The persistence of high smoking prevalence in several MENA countries supports stronger tobacco taxation, smoke‐free legislation, cessation services, restrictions on advertising and promotion, and public education campaigns [32]. These measures are especially important because smoking can compound the cardiovascular effects of hypertension, dyslipidaemia, diabetes, and other cardiometabolic risks.

Diabetes and unhealthy dietary patterns are important contextual contributors to IHD burden in MENA, particularly because they are closely linked to obesity, dyslipidaemia, and hypertension [33]. Several countries with high IHD prevalence also have high levels of diabetes and related cardiometabolic risks. However, because diabetes was not among the leading attributable risk factors highlighted in the present analysis, we interpret it here as an important interacting condition rather than as a primary driver equivalent to elevated systolic blood pressure, high LDL cholesterol, ambient particulate matter pollution, high BMI, or smoking [34].

Dietary and lifestyle interventions remain relevant because they influence several priority drivers simultaneously, including blood pressure, LDL cholesterol, body weight, and diabetes risk. Greater adherence to healthy dietary patterns, such as DASH or Mediterranean‐style diets, together with reductions in ultra‐processed foods, excess salt, trans fats, and sugar‐sweetened beverages, may therefore contribute to broader cardiovascular risk reduction [35, 36].

Overall, the ranking of attributable risks suggests that IHD prevention in the MENA region should not treat all risk factors as equal priorities. While CVD risk factors are prevalent throughout the region, the optimal policy response must be stratified by each country's specific epidemiological profile and health‐system resources. In high‐income countries, particularly those within the Gulf Cooperation Council, where the burden of obesity and diet‐related cardiometabolic risk is disproportionately high, policies should prioritize the regulation of food environments, public initiatives to promote physical activity, and aggressive screening for early‐onset diabetes and dyslipidaemia. Conversely, in countries with lower sociodemographic indices or those navigating significant health system transitions and instability, policy focus should shift toward strengthening primary healthcare access, ensuring the consistent availability of essential antihypertensive and lipid‐lowering medications, and addressing structural environmental determinants such as air quality. By tailoring national health strategies to these distinct regional clusters, rather than applying a homogeneous approach, policymakers can more effectively direct resources to where they are most needed.

Several limitations were identified in this study. First, data gaps for certain countries in MENA were addressed through GBD modeling, highlighting the need for more robust and consistent health information systems across the region. Second, source availability and data quality differed across countries and over time, and this heterogeneity may have affected the comparability of some estimates. Third, attributable fractions for individual risk factors may overlap because several risks share causal pathways and cluster within the same populations. Therefore, the percentages attributable to separate risk factors should not be summed to estimate the total preventable burden, and this analysis did not estimate the joint effects of combinations of risks within specific countries or subpopulations. Fourth, abdominal obesity could not be examined separately from BMI, despite evidence that regional and ethnic differences in fat distribution, particularly in some MENA population groups, may not be adequately captured by BMI alone. Finally, the present study is based entirely on model‐derived GBD 2021 estimates rather than primary individual‐level data. Although the GBD framework applies standardized and validated modeling strategies, including comparative risk assessment methods and cause‐of‐death ensemble modeling, the outputs remain statistical estimates that depend on input data availability, model assumptions, and covariate selection. Accordingly, associations between risk factors and IHD burden reflect modeled population‐attributable fractions based on established epidemiological evidence, but they should not be interpreted as demonstrating direct causal effects within specific countries or subpopulations. Moreover, given the ecological and aggregated nature of the analysis, causal inference at the individual or national policy level is not possible. The findings should therefore be interpreted as descriptive and comparative estimates intended to inform prioritization rather than to establish causality.

5. Conclusion

By jointly examining temporal trends, inter‐country heterogeneity, SDI‐related patterns, and attributable risk factors, this study provides novel evidence to guide prioritized, context‐sensitive, and evidence‐based policy action to reduce the persistently high burden of IHD in the MENA region. Despite declines in mortality and DALY rates since 1990, IHD prevalence remains high, with substantial variation across countries and a disproportionate impact among males and older adults. The high contribution of modifiable risk factors, such as elevated systolic blood pressure (49.6%), high LDL cholesterol (39.6%), ambient particulate matter pollution (28.2%), high body mass index (22.4%), and smoking (20.5%), demonstrates that a large share of the IHD burden is preventable through effective public health and clinical policies. Given their leading contributions, hypertension control and lipid management should be treated as first‐line regional priorities, alongside population‐level strategies targeting ambient particulate matter pollution, smoking, and overweight and obesity. Policymakers should prioritize large‑scale hypertension detection and control programs, expand access to lipid‑lowering and cardioprotective therapies, and strengthen national tobacco control legislation. Given the substantial impact of overweight and obesity, comprehensive strategies promoting healthy diets, physical activity, and the regulation of unhealthy food environments are essential. Investment in air‑quality improvements is also critical in a region where PM2.5 exposure is among the highest globally. Countries with rising prevalence, such as Saudi Arabia, Egypt, and Oman, require intensified surveillance, early detection, and risk‑factor management, while countries with declining age‐standardized rates underscore the value of sustained prevention efforts. These country‐specific differences indicate that policy responses should be adapted to national trends, risk profiles, and health‐system capacity. Overall, implementing integrated cardiovascular prevention policies, improving healthcare system capacity, and addressing socioeconomic determinants of health will be key to reducing the high level of IHD‐related burden observed throughout the MENA region.

Author Contributions

S.S., N.K., and A.A.K. designed the study. S.S. analyzed the data and performed the statistical analyzes. S.S., A.G.J., S.E.M., F.A., M.R., M.J.M.S., N.K., and A.A.K. validated the findings, prepared the figures and tables, and drafted the initial manuscript. All authors have read and approved the final version of the manuscript. Saeid Safiri, as manuscript guarantor, had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

Ethics Statement

This secondary analysis of publicly available GBD 2021 data was conducted in 2025 and approved by the Ethics Committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1403.560).

Consent

Patient consent and consent for publication were not required because this study used anonymised, aggregated, publicly available secondary data.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

Saeid Safiri and Ali‐Asghar Kolahi, as manuscript guarantors, affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Figure S1: Percentage change in age‐standardized prevalence rates due to ischemic heart disease in the MENA region, by sex, 1990–2021.

Figure S2: Percentage change in age‐standardized mortality rates due to ischemic heart disease in the MENA region, by sex, 1990–2021.

Figure S3: Percentage change in age‐standardized DALY rates due to ischemic heart disease in the MENA region, by sex, 1990–2021.

Figure S4: Percentage of DALYs attributable to selected risk factors for ischemic heart disease among males in the MENA region in 2021.

Figure S5: Percentage of DALYs attributable to selected risk factors for ischemic heart disease among females in the MENA region in 2021.

Table S1: Sequelae for ischemic heart disease and their associated disability weights.

Table S2: Prevalence of ischemic heart disease in 1990 and 2021 and the percentage change in age‐standardized rates (ASRs) per 100,000 in the Middle East and North Africa region (Generated from data available from http://ghdx.healthdata.org/gbd-results-tool).

Table S3: Deaths due to ischemic heart disease in 1990 and 2021 and the percentage change in age‐standardized rates (ASRs) per 100,000 in the Middle East and North Africa region (Generated from data available from http://ghdx.healthdata.org/gbd-results-tool).

Table S4: DALYs due to ischemic heart disease in 1990 and 2021 and the percentage change in age‐standardized rates (ASRs) per 100,000 in the Middle East and North Africa region (Generated from data available from http://ghdx.healthdata.org/gbd-results-tool).

Data Availability Statement

The data used for these analyzes are all publicly available at http://ghdx.healthdata.org/gbd-results-tool.