Abstract
Purpose
To characterize the global burden and long-term trends of ischemic heart disease (IHD) among women aged ≥55 years, with particular attention to regional, socioeconomic and age-specific variation.
Patients and methods
From the Global Burden of Disease Study 2021 we extracted disability-adjusted life-year (DALY), death and incidence counts and age-standardized rates (ASRs) for IHD in women aged ≥55 years across 204 countries, 21 regions and five Socio-demographic Index (SDI) strata. Estimated annual percentage changes (EAPCs) were derived by log-linear regression of ln (ASR) on calendar year. Trends were examined by region, by SDI and across nine five-year age bands from 55–59 to ≥95 years.
Results
Globally, DALYs rose from 40.0 to 60.6 million (EAPC 1.23), deaths from 2.36 to 3.71 million (EAPC 1.39) and incident cases from 5.69 to 11.69 million (EAPC 2.20), while ASRs fell (DALY EAPC −1.53; death EAPC −1.60; incidence EAPC −0.57). Burden was highest in Central Asia (19,862.64/100 000), Eastern Europe (17,690.80) and North Africa and the Middle East (16,239.37), and lowest in the high-income Asia Pacific (1359.50), Australasia (2469.28) and Western Europe (2590.61). Western Europe (−4.46), Australasia (−5.27) and the high-income Asia Pacific (−3.83) declined fastest; East Asia (0.23), South Asia (0.00) and southern sub-Saharan Africa (0.65) rose or stayed flat. Incidence in women aged ≥95 years grew fastest (EAPC 4.49).
Conclusion
Older women bear a growing absolute IHD burden whose age-standardized intensity is falling unevenly worldwide. These findings highlight the need for clinicians to recognize the increasing IHD burden in older women and for public health systems to incorporate age- and sex-specific burden patterns into preventive care and health-resource planning.
Keywords: ischemic heart disease, women, aging, global burden of disease, estimated annual percentage change
Introduction
Ischemic heart disease (IHD) is the single largest contributor to global mortality and disability-adjusted life-years (DALYs) and has occupied the top rank of the Global Burden of Disease (GBD) cause hierarchy for more than two decades.1–3 Driven by population aging, urbanization and the diffusion of cardiometabolic risk factors such as hypertension, dyslipidemia, diabetes mellitus and unhealthy diet, the absolute number of incident IHD cases, deaths and DALYs has continued to rise even as age-standardized rates have started to fall in high-income settings.4,5 The disease imposes substantial pressure on health systems, household finances and labor productivity, and disparities in its burden between regions and between sexes have widened rather than narrowed.6,7
Cardiovascular disease in women has long been understudied, under-recognized, under-diagnosed and under-treated.6,8 Although the conventional view emphasized a protective effect of endogenous estrogen and a later, milder presentation of IHD in women, accumulating evidence shows that incidence and mortality climb sharply after menopause, and that women aged 55 years and older now bear an absolute IHD burden that is comparable to or larger than that of men of the same age.9,10 Older women also experience more atypical clinical presentations, a higher prevalence of multimorbidity and frailty, and lower rates of guideline-concordant secondary prevention, all of which translate into higher case fatality and longer-term disability.11–13
Previous GBD-based studies have provided important evidence on the global burden and temporal patterns of cardiovascular diseases and IHD, as well as their variation across regions and socioeconomic settings However, important gaps remain. Most global or regional analyses of IHD report only mortality or incidence, rarely the combined DALY perspective that captures fatal and non-fatal loss simultaneously; many have not examined the burden over the full 1990–2021 period, and very few stratify analyses into the older age bands (55–59 through ≥95 years) that are most relevant for clinical and policy decision-making in aging societies.4,5,7,14 In addition, few studies have specifically focused on women aged ≥55 years while simultaneously evaluating DALYs, deaths, and incidence across detailed age groups and geographic settings. Quantitative tools such as the estimated annual percentage change (EAPC), which summarizes the linear trend of a log-transformed age-standardized rate, have rarely been applied to women aged ≥55 years across all 204 countries and 21 GBD regions, and the combined assessment of EAPC with the Socio-demographic Index (SDI) in this population has also received limited attention.15,16
To address these gaps, we used the GBD 2021 estimates to systematically describe the global, regional and national burden of IHD in women aged 55 years and older from 1990 to 2021. We had five aims: (i) to map the geographic distribution of age-standardized DALY, death and incidence rates in 204 countries and identify high- and low-burden regions; (ii) to quantify long-term trends from 1990 to 2021 using the EAPC; (iii) to examine age-stratified burden across nine five-year age bands from 55–59 to ≥95 years; (iv) to compare burden and EAPC across SDI strata and the 21 GBD regions to characterize socioeconomic inequalities; and (v) to identify regions and countries with the highest and fastest-rising burdens, providing high-resolution evidence for sex-, age- and region-specific prevention and control strategies.
Methods
Study Design and Data Source
This study was a population-based, cross-country descriptive analysis of routinely modeled estimates from the GBD Study 2021, the most recent iteration of the GBD project coordinated by the Institute for Health Metrics and Evaluation.1–3 GBD 2021 integrates more than 100 000 data sources—including vital registration, verbal autopsy, surveillance systems, surveys, hospital and claims data—into a unified Bayesian meta-regression framework (DisMod-MR 2.1 and the Cause of Death Ensemble model, CODEm) to generate internally consistent estimates of incidence, prevalence, deaths, years of life lost (YLLs), years lived with disability (YLDs) and DALYs by age, sex, year, location and cause.1,2 All estimates and corresponding 95% uncertainty intervals (UIs) were obtained from the Global Health Data Exchange (http://ghdx.healthdata.org/gbd-results-tool). Since this study was a secondary-analysis based on publicly available aggregated population-level data from the Global Burden of Disease Study 2021 without access to any individual-level human participant information, it was exempted from ethical approval in accordance with Items 1 and 2, Article 32 of the Measures for Ethical Review of Life Science and Medical Research Involving Human Subjects, issued on February 18, 2023, China. For the use of identified data in GBD study, a waiver of informed consent has been approved by the University of Washington Institutional Review Board. This study did not involve individual participants. The ethics approval can be found at https://www.healthdata.org/.
Case Definition and Study Population
IHD was defined according to the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes I20–I25 and the equivalent ICD-9 codes used by GBD case definitions.1 The study population comprised women aged 55 years and older across 204 countries and territories grouped by GBD into 21 regions and seven super-regions, and stratified by five SDI quintiles (low, low-middle, middle, high-middle and high). Age was further stratified into nine five-year groups (55–59, 60–64, 65–69, 70–74, 75–79, 80–84, 85–89, 90–94 and ≥95 years).
Indicators
Three core measures were extracted for each location, year and age band: the number and age-standardized rate (ASR, per 100 000) of incidence, deaths, and DALYs. ASRs were computed by GBD using the GBD world population standard, allowing valid comparison across populations with differing age structures. DALYs combine YLLs and YLDs and therefore index the total fatal plus non-fatal burden of disease.
Estimated Annual Percentage Change
Long-term trends of each ASR between 1990 and 2021 were summarized by the EAPC. The natural logarithm of the ASR was regressed on calendar year using ordinary least squares, ln(ASR) = α + β × year + ε, and the EAPC and its 95% confidence interval (CI) were derived as (exp(β) − 1) × 100.15,16 An ASR was considered to be increasing if both the EAPC point estimate and the lower 95% CI bound were greater than zero, decreasing if both the EAPC and the upper 95% CI bound were less than zero, and stable otherwise.
Statistical Analysis
Descriptive analyses were conducted globally, by SDI quintile, by GBD region, and by country. Geographic distributions, age-specific rates, long-term age-stratified trends, regional comparisons of ASRs and EAPCs, and rankings of the top and bottom three regions and countries by ASR, absolute case-number growth, and EAPC were evaluated. Burden and trends by SDI quintile are summarized in Supplementary Table S1, and country-level top and bottom three rankings by age-standardized rate and by EAPC are provided in Supplementary Tables S2 and S3, respectively. All analyses were performed in R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria), with two-sided p < 0.05 regarded as statistically significant when applicable. This study followed the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).17
Results
Geographic Distribution of Age-Standardized Rates and EAPCs
In 2021, the age-standardized DALY, death and incidence rates of IHD in women aged ≥55 years exhibited substantial spatial heterogeneity across the 204 countries and territories (Figure 1A). High-burden regions were concentrated in Central Asia, Eastern Europe, North Africa and the Middle East, while low-burden regions included Western Europe, Australasia and the high-income Asia Pacific. The corresponding EAPCs from 1990 to 2021 showed clear geographic polarization (Figure 1B): high-income regions had negative EAPCs across all three indicators, indicating continued declines in burden, whereas sub-Saharan Africa, South Asia and parts of East Asia displayed positive EAPCs, indicating that the age-standardized burden was rising. Similar geographic patterns were observed for the age-standardized death rate and its corresponding EAPC (Figure 1C and D), and for the age-standardized incidence rate and its corresponding EAPC (Figure 1E and F). Overall, high-income regions had negative EAPCs across all three indicators, indicating continued declines in the age-standardized burden, whereas sub-Saharan Africa, South Asia and parts of East Asia displayed positive EAPCs, indicating that the age-standardized burden was rising.
Figure 1.
Global geographic distribution of age-standardized rates of ischemic heart disease in women aged 55 years and older in 2021, and EAPCs from 1990 to 2021, across 204 countries. (A) Age-standardized DALY rate, 2021. (B) EAPC of age-standardized DALY rate, 1990–2021. (C) Age-standardized death rate, 2021. (D) EAPC of age-standardized death rate, 1990–2021. (E) Age-standardized incidence rate, 2021. (F) EAPC of age-standardized incidence rate, 1990–2021.
Abbreivations: DALY, disability-adjusted life-years; EAPC, estimated annual percentage change.
Age-Specific Burden Across 21 Regions
In 2021, age-specific DALY, death and incidence rates all rose markedly with age in each of the 21 GBD regions, with the steepest increases observed in women aged ≥85 years (Figure 2A–C).
Figure 2.
Age-specific rates of ischemic heart disease in women aged 55 years and older across the 21 GBD regions in 2021. (A) DALY rate per 100 000. (B) Death rate per 100 000. (C) Incidence rate per 100 000.
Global and SDI-Stratified Burden and Trends
Globally, between 1990 and 2021, DALYs in women aged ≥55 years rose from 39.99 to 60.57 million (EAPC 1.23, 95% CI 1.16 to 1.29), and the age-standardized DALY rate fell from 11 883.47 to 7 690.92 per 100 000 (EAPC −1.53, 95% CI −1.59 to −1.48; Table 1). Deaths increased from 2.36 to 3.71 million (EAPC 1.39, 95% CI 1.34 to 1.44), and the age-standardized death rate decreased from 751.69 to 471.50 per 100 000 (EAPC −1.60, 95% CI −1.65 to −1.55; Table 2). Incident cases nearly doubled from 5.69 to 11.69 million (EAPC 2.20, 95% CI 2.10 to 2.31), while the age-standardized incidence rate fell more modestly from 1 685.45 to 1 484.09 per 100 000 (EAPC −0.57, 95% CI −0.64 to −0.51; Table 3). When stratified by SDI, high-SDI regions showed the largest declines in age-standardized DALY rate (EAPC −3.82), whereas absolute burden grew rapidly in low- and low-middle-SDI regions, with their age-standardized rates falling only modestly (Supplementary Table S1).
Table 1.
DALY Counts and Age-Standardized DALY Rate of Ischemic Heart Disease in Women Aged 55 years and Older Globally and by Region, 1990 and 2021
| Location | All-Age Count, 1990 (95% UI) | All-Age Count, 2021 (95% UI) | EAPC of Count, 1990–2021 (95% CI) |
Age-Standardized Rate Per 100 000, 1990 (95% UI) |
Age-Standardized Rate Per 100 000, 2021 (95% UI) |
EAPC of Age-Standardized Rate, 1990–2021 (95% CI) |
|---|---|---|---|---|---|---|
| Global | 39986118.33(39,042,412.75,40,929,823.90) | 60,569,536.51(58,536,681.50,62,602,391.52) | 1.23(1.16,1.29) | 11,883.47(11,879.70,11,887.24) | 7690.92(7688.99,7692.86) | −1.53(−1.59,-1.48) |
| High-middle SDI | 13022280.52(12,744,836.48,13,299,724.55) | 17,572,900.52(16,809,391.61,18,336,409.44) | 0.67(0.46,0.87) | 14,446.81(14,438.58,14,455.05) | 9045.09(9040.85,9049.33) | −1.79(−2.04,-1.55) |
| High SDI | 12115005.54(11,743,931.29,12,486,079.79) | 8,101,373.56(7,682,482.93,8,520,264.19) | −1.60(−1.73,-1.46) | 10,361.71(10,355.81,10,367.61) | 3472.14(3469.65,3474.63) | −3.82(−3.95,-3.69) |
| Low-middle SDI | 5466223.08(5,206,775.78,5,725,670.37) | 12,815,263.25(12,307,788.83,13,322,737.67) | 2.91(2.79,3.03) | 12,248.65(12,237.73,12,259.60) | 10,945.78(10,939.65,10,951.92) | −0.27(−0.35,-0.18) |
| Low SDI | 1766046.11(1,637,769.61,1,894,322.60) | 3,461,068.18(3,253,123.19,3,669,013.17) | 2.24(2.13,2.35) | 10,827.80(10,810.25,10,845.40) | 9280.92(9270.52,9291.34) | −0.46(−0.56,-0.36) |
| Middle SDI | 7551425.23(7,294,880.85,7,807,969.60) | 18,553,078.90(17,816,828.37,19,289,329.43) | 2.99(2.91,3.07) | 9846.46(9838.82,9854.11) | 8180.55(8176.78,8184.31) | −0.54(−0.59,-0.49) |
| Andean Latin America | 114370.19(106,902.12,121,838.26) | 213,584.70(196,129.94,231,039.46) | 1.81(1.38,2.25) | 7219.73(7177.47,7262.23) | 4204.54(4186.71,4222.42) | −2.12(−2.52,-1.71) |
| Australasia | 271000.80(261,993.45,280,008.15) | 146,277.11(136,559.85,155,994.36) | −2.35(−2.45,-2.25) | 11,644.56(11,600.32,11,688.94) | 2469.28(2456.29,2482.33) | −5.27(−5.38,-5.15) |
| Caribbean | 329036.40(318,530.25,339,542.55) | 441,810.66(416,791.64,466,829.68) | 0.86(0.71,1.02) | 15,372.21(15,318.31,15,426.35) | 8850.06(8823.86,8876.32) | −1.82(−2.00,-1.65) |
| Central Asia | 1072492.78(1,051,168.69,1,093,816.87) | 1,373,813.53(1,321,557.98,1,426,069.08) | 0.11(−0.14,0.35) | 23,792.86(23,747.14,23,838.67) | 19,862.64(19,828.56,19,896.76) | −1.12(−1.43,-0.81) |
| Central Europe | 2661991.84(2,617,317.16,2,706,666.53) | 2,307,209.50(2,223,301.83,2,391,117.17) | −0.75(−0.86,-0.64) | 18,527.47(18,504.28,18,550.71) | 9186.16(9174.12,9198.23) | −2.67(−2.80,-2.54) |
| Central Latin America | 620654.73(609,729.21,631,580.25) | 1,588,364.45(1,522,815.06,1,653,913.85) | 2.97(2.72,3.23) | 9999.55(9973.56,10,025.63) | 7150.31(7139.16,7161.47) | −1.24(−1.49,-0.98) |
| Central Sub-Saharan Africa | 183438.90(153,061.02,213,816.77) | 379,923.00(319,005.52,440,840.47) | 2.03(1.92,2.15) | 11,335.33(11,271.22,11,400.01) | 9448.18(9415.43,9481.08) | −0.76(−0.84,-0.69) |
| East Asia | 4644183.61(4,323,243.18,4,965,124.04) | 13,087,178.04(12,049,234.83,14,125,121.25) | 3.79(3.57,4.00) | 7406.87(7398.69,7415.06) | 7039.84(7035.98,7043.71) | 0.23(−0.08,0.54) |
| Eastern Europe | 7089306.98(6,971,310.52,7,207,303.44) | 7,325,352.13(6,960,657.36,7,690,046.89) | −0.38(−0.76,-0.00) | 23,021.71(23,003.87,23,039.57) | 17,690.80(17,677.73,17,703.88) | −1.34(−1.80,-0.88) |
| Eastern Sub-Saharan Africa | 326941.90(295,161.10,358,722.70) | 685,222.86(631,392.63,739,053.09) | 2.29(2.19,2.39) | 6119.09(6095.87,6142.45) | 5569.95(5556.04,5583.90) | −0.46(−0.52,-0.39) |
| High-income Asia Pacific | 821350.60(788,934.50,853,766.69) | 846,346.26(771,585.52,921,107.00) | 0.05(−0.05,0.15) | 4396.93(4387.22,4406.66) | 1359.50(1356.25,1362.75) | −3.83(−3.97,-3.68) |
| High-income North America | 4430588.32(4,270,526.86,4,590,649.79) | 3,165,761.08(3,019,893.32,3,311,628.85) | −1.51(−1.70,-1.32) | 11,715.44(11,704.35,11,726.54) | 4608.07(4602.90,4613.25) | −3.40(−3.59,-3.22) |
| North Africa and Middle East | 2679301.64(2,548,520.73,2,810,082.54) | 5,212,830.52(4,924,756.47,5,500,904.58) | 2.10(2.02,2.18) | 22,523.00(22,494.65,22,551.38) | 16,239.37(16,224.86,16,253.89) | −1.09(−1.14,-1.03) |
| Oceania | 27943.66(24,673.91,31,213.41) | 67,050.43(60,194.83,73,906.04) | 2.82(2.80,2.85) | 14,182.71(13,986.08,14,383.33) | 13,289.22(13,179.79,13,399.65) | −0.21(−0.31,-0.12) |
| South Asia | 4751286.54(4,451,671.19,5,050,901.88) | 13,272,271.17(12,638,758.80,13,905,783.54) | 3.55(3.35,3.75) | 11,470.44(11,459.27,11,481.63) | 11,093.15(11,087.02,11,099.28) | 0.00(−0.18,0.19) |
| Southeast Asia | 1919227.86(1,811,890.16,2,026,565.57) | 4,410,775.74(4,159,873.82,4,661,677.67) | 2.63(2.59,2.66) | 9544.00(9529.95,9558.08) | 8073.95(8066.23,8081.67) | −0.56(−0.65,-0.48) |
| Southern Latin America | 411021.58(399,408.77,422,634.40) | 304,922.69(291,956.35,317,889.03) | −0.71(−0.86,-0.55) | 9689.92(9659.87,9720.06) | 3383.24(3371.14,3395.37) | −3.08(−3.27,-2.90) |
| Southern Sub-Saharan Africa | 121718.34(113,215.17,130,221.52) | 317,703.79(302,301.15,333,106.43) | 3.13(2.67,3.58) | 5291.11(5260.89,5321.50) | 6312.37(6289.45,6335.39) | 0.65(0.22,1.08) |
| Tropical Latin America | 737596.54(720,952.26,754,240.82) | 1,131,969.95(1,094,490.28,1,169,449.62) | 1.36(1.28,1.44) | 10,125.34(10,101.40,10,149.35) | 4685.74(4677.10,4694.38) | −2.50(−2.59,-2.42) |
| Western Europe | 6113829.11(5,922,018.73,6,305,639.48) | 2,970,683.80(2,780,598.37,3,160,769.23) | −2.60(−2.71,-2.50) | 9493.07(9485.37,9500.77) | 2590.61(2587.48,2593.74) | −4.46(−4.59,-4.34) |
| Western Sub-Saharan Africa | 658836.01(604,679.44,712,992.58) | 1,320,485.09(1,213,056.82,1,427,913.36) | 2.23(2.07,2.38) | 10,231.04(10,205.32,10,256.84) | 9339.40(9322.50,9356.33) | −0.29(−0.41,-0.18) |
Abbreviations: DALY, disability-adjusted life-years; EAPC, estimated annual percentage change; SDI, Socio-demographic Index; UI, uncertainty interval.
Table 2.
Death Counts and Age-Standardized Death Rate of Ischemic Heart Disease in Women Aged 55 years and Older Globally and by Region, 1990 and 2021
| Location | All-Age Count, 1990 (95% UI) | All-Age Count, 2021 (95% UI) | EAPC of Count, 1990–2021 (95% CI) |
Age-Standardized Rate Per 100 000, 1990 (95% UI) |
Age-Standardized Rate Per 100 000, 2021 (95% UI) |
EAPC of Age-Standardized Rate, 1990–2021 (95% CI) |
|---|---|---|---|---|---|---|
| Global | 2359177.51(2,290,726.52,2,427,628.51) | 3,711,871.63(3,550,152.37,3,873,590.90) | 1.39(1.34,1.44) | 751.69(750.69,752.68) | 471.50(471.02,471.98) | −1.60(−1.65,-1.55) |
| High-middle SDI | 796655.69(776,032.62,817,278.76) | 1,194,737.59(1,132,888.43,1,256,586.75) | 1.11(0.95,1.27) | 956.91(954.66,959.16) | 609.01(607.92,610.10) | −1.67(−1.87,-1.47) |
| High SDI | 818015.79(784,020.03,852,011.55) | 607,276.49(563,876.14,650,676.83) | −1.24(−1.35,-1.14) | 686.10(684.60,687.61) | 229.84(229.24,230.44) | −3.80(−3.91,-3.69) |
| Low-middle SDI | 263525.80(251,449.01,275,602.58) | 654,517.95(629,417.53,679,618.36) | 3.16(3.04,3.27) | 671.80(669.00,674.61) | 607.88(606.36,609.40) | −0.18(−0.28,-0.09) |
| Low SDI | 82214.70(76,743.65,87,685.75) | 171,136.53(161,433.09,180,839.97) | 2.51(2.39,2.63) | 582.84(578.29,587.43) | 520.11(517.42,522.81) | −0.27(−0.40,-0.15) |
| Middle SDI | 394845.34(381,021.47,408,669.22) | 1,079,857.08(1,029,069.39,1,130,644.78) | 3.43(3.35,3.51) | 596.85(594.77,598.93) | 507.16(506.19,508.13) | −0.40(−0.48,-0.33) |
| Andean Latin America | 6785.78(6374.11,7197.46) | 13,496.89(12,383.15,14,610.63) | 2.12(1.68,2.56) | 452.83(441.95,463.95) | 267.03(262.54,271.58) | −2.05(−2.45,-1.66) |
| Australasia | 17890.13(17,143.53,18,636.74) | 11,925.65(10,897.87,12,953.44) | −1.62(−1.73,-1.51) | 767.87(756.56,779.33) | 183.87(180.50,187.30) | −4.82(−4.91,-4.73) |
| Caribbean | 18895.82(18,348.96,19,442.69) | 26,255.93(24,899.92,27,611.94) | 0.97(0.83,1.10) | 933.84(919.97,947.95) | 511.05(504.83,517.32) | −1.98(−2.16,-1.79) |
| Central Asia | 64540.86(62,847.33,66,234.39) | 81,482.09(78,323.11,84,641.07) | 0.23(0.03,0.44) | 1489.94(1478.21,1501.76) | 1257.61(1248.81,1266.45) | −0.98(−1.24,-0.71) |
| Central Europe | 163687.97(160,274.46,167,101.48) | 169,490.11(162,090.77,176,889.44) | −0.07(−0.18,0.05) | 1208.44(1202.23,1214.69) | 641.93(638.85,645.02) | −2.38(−2.50,-2.27) |
| Central Latin America | 35746.94(34,960.34,36,533.54) | 100,900.64(96,220.95,105,580.34) | 3.41(3.16,3.67) | 635.93(628.94,643.01) | 461.43(458.58,464.30) | −1.10(−1.37,-0.82) |
| Central Sub-Saharan Africa | 8381.28(7093.25,9669.31) | 18,842.36(16,057.61,21,627.11) | 2.33(2.19,2.46) | 639.34(621.81,657.51) | 546.29(537.68,555.08) | −0.69(−0.76,-0.62) |
| East Asia | 243389.88(227,218.41,259,561.36) | 860,243.77(786,312.32,934,175.22) | 4.60(4.36,4.84) | 465.95(463.57,468.35) | 488.58(487.53,489.63) | 0.60(0.25,0.95) |
| Eastern Europe | 445346.26(435,909.05,454,783.47) | 501,108.97(473,334.32,528,883.62) | 0.02(−0.29,0.32) | 1536.22(1531.37,1541.09) | 1179.12(1175.79,1182.46) | −1.27(−1.69,-0.85) |
| Eastern Sub-Saharan Africa | 15400.17(13,984.61,16,815.72) | 34,593.15(31,806.43,37,379.88) | 2.55(2.47,2.64) | 333.61(327.57,339.82) | 317.94(314.36,321.56) | −0.29(−0.35,-0.23) |
| High-income Asia Pacific | 55060.39(52,301.72,57,819.07) | 71,749.51(63,681.05,79,817.96) | 0.90(0.75,1.04) | 309.99(307.32,312.68) | 95.68(94.91,96.46) | −3.75(−3.94,-3.55) |
| High-income North America | 302735.91(287,609.53,317,862.29) | 222,850.21(207,734.81,237,965.61) | −1.42(−1.60,-1.24) | 758.98(756.25,761.71) | 298.94(297.67,300.22) | −3.38(−3.56,-3.21) |
| North Africa and Middle East | 139807.33(133,271.32,146,343.34) | 289,011.31(273,659.38,304,363.24) | 2.46(2.38,2.55) | 1338.99(1331.58,1346.44) | 1012.07(1008.21,1015.93) | −0.84(−0.94,-0.74) |
| Oceania | 1255.91(1127.38,1384.44) | 3124.75(2847.54,3401.97) | 2.93(2.88,2.98) | 784.64(731.91,841.99) | 730.12(702.13,759.21) | −0.24(−0.32,-0.15) |
| South Asia | 215296.38(201,827.23,228,765.54) | 657,074.29(626,824.23,687,324.35) | 3.93(3.73,4.14) | 593.43(590.61,596.26) | 597.61(596.10,599.12) | 0.19(−0.02,0.40) |
| Southeast Asia | 96826.58(91,593.86,102,059.30) | 237,715.80(225,114.20,250,317.40) | 2.88(2.83,2.93) | 540.35(536.78,543.94) | 478.09(476.13,480.07) | −0.41(−0.51,-0.32) |
| Southern Latin America | 26404.45(25,517.90,27,291.00) | 21,108.32(19,972.75,22,243.90) | −0.40(−0.54,-0.26) | 651.96(643.94,660.07) | 222.14(219.13,225.18) | −3.10(−3.29,-2.91) |
| Southern Sub-Saharan Africa | 6945.01(6431.49,7458.53) | 17,569.79(16,707.20,18,432.38) | 2.98(2.54,3.43) | 326.17(318.37,334.14) | 388.40(382.33,394.58) | 0.59(0.18,1.01) |
| Tropical Latin America | 39504.61(38,388.02,40,621.21) | 62,308.75(59,565.34,65,052.16) | 1.54(1.46,1.62) | 600.33(594.13,606.59) | 258.66(256.63,260.70) | −2.65(−2.76,-2.54) |
| Western Europe | 420573.45(403,333.96,437,812.94) | 242,464.20(222,587.05,262,341.36) | −2.03(−2.13,-1.92) | 635.16(633.20,637.12) | 184.71(183.94,185.48) | −4.23(−4.34,-4.11) |
| Western Sub-Saharan Africa | 34702.39(31,977.97,37,426.80) | 68,555.12(63,632.66,73,477.58) | 2.19(2.05,2.34) | 593.31(586.71,599.99) | 555.41(550.97,559.88) | −0.20(−0.31,-0.09) |
Abbreviations: EAPC, estimated annual percentage change; SDI, Socio-demographic Index; UI, uncertainty interval.
Table 3.
Incident Case Counts and Age-Standardized Incidence Rate of Ischemic Heart Disease in Women Aged 55 years and Older Globally and by Region, 1990 and 2021
| Location | All-Age Count, 1990 (95% UI) | All-Age Count, 2021 (95% UI) | EAPC of Count, 1990–2021 (95% CI) |
Age-Standardized Rate Per 100 000, 1990 (95% UI) |
Age-Standardized Rate Per 100 000, 2021 (95% UI) |
EAPC of Age-Standardized Rate, 1990–2021 (95% CI) |
|---|---|---|---|---|---|---|
| Global | 5688809.50(4,902,798.03,6,474,820.97) | 11,686,302.42(10,073,157.28,13,299,447.55) | 2.20(2.10,2.31) | 1685.45(1684.03,1686.87) | 1484.09(1483.24,1484.94) | −0.57(−0.64,-0.51) |
| High-middle SDI | 1833197.24(1,579,266.09,2,087,128.39) | 3,410,473.43(2,940,988.97,3,879,957.88) | 1.78(1.67,1.88) | 2048.95(2045.84,2052.07) | 1762.64(1760.77,1764.52) | −0.72(−0.84,-0.60) |
| High SDI | 1411474.04(1,236,168.70,1,586,779.38) | 1,444,461.70(1,269,332.94,1,619,590.46) | −0.19(−0.52,0.13) | 1209.63(1207.61,1211.65) | 648.45(647.36,649.55) | −2.31(−2.60,-2.02) |
| Low-middle SDI | 914792.53(777,246.05,1,052,339.01) | 2,325,220.76(1,998,562.60,2,651,878.91) | 3.00(2.93,3.07) | 2103.56(2098.94,2108.19) | 2010.89(2008.24,2013.55) | −0.25(−0.31,-0.20) |
| Low SDI | 298672.02(249,078.66,348,265.39) | 672,500.52(565,311.06,779,689.97) | 2.53(2.44,2.63) | 1933.81(1926.03,1941.63) | 1836.51(1831.81,1841.23) | −0.33(−0.40,-0.25) |
| Middle SDI | 1223396.71(1,032,806.53,1,413,986.89) | 3,823,602.70(3,263,805.86,4,383,399.54) | 3.71(3.67,3.76) | 1616.40(1613.29,1619.52) | 1686.28(1684.57,1687.99) | 0.11(0.06,0.16) |
| Andean Latin America | 15703.99(13,236.48,18,171.49) | 46,658.99(39,273.28,54,044.71) | 3.57(3.49,3.66) | 988.82(973.22,1004.67) | 913.31(905.03,921.64) | −0.42(−0.50,-0.34) |
| Australasia | 31849.69(28,291.78,35,407.60) | 46,468.83(40,137.79,52,799.88) | 1.04(0.81,1.28) | 1387.64(1372.27,1403.16) | 878.99(870.83,887.22) | −1.63(−1.83,-1.42) |
| Caribbean | 37837.47(32,559.31,43,115.64) | 77,897.72(66,984.60,88,810.83) | 2.22(2.12,2.32) | 1779.71(1761.28,1798.37) | 1547.68(1536.76,1558.65) | −0.56(−0.68,-0.44) |
| Central Asia | 127123.77(113,910.03,140,337.51) | 252,752.60(230,947.47,274,557.72) | 2.15(2.08,2.21) | 2846.37(2830.47,2862.36) | 3739.27(3724.34,3754.25) | 0.93(0.78,1.09) |
| Central Europe | 292488.79(261,627.81,323,349.78) | 319,781.56(288,371.13,351,191.99) | −0.09(−0.34,0.17) | 2059.64(2051.85,2067.47) | 1316.89(1312.23,1321.57) | −1.95(−2.19,-1.71) |
| Central Latin America | 90401.61(76,069.74,104,733.48) | 282,527.01(240,481.68,324,572.33) | 3.66(3.58,3.73) | 1442.02(1432.20,1451.92) | 1260.69(1256.04,1265.37) | −0.60(−0.68,-0.51) |
| Central Sub-Saharan Africa | 25954.10(21,468.28,30,439.91) | 62,662.74(53,055.36,72,270.13) | 2.63(2.53,2.72) | 1653.43(1627.95,1679.50) | 1551.40(1538.03,1564.93) | −0.30(−0.34,-0.26) |
| East Asia | 898487.99(748,948.89,1,048,027.08) | 3,138,776.06(2,651,105.12,3,626,447.00) | 4.17(4.10,4.24) | 1460.51(1456.89,1464.14) | 1658.82(1656.96,1660.67) | 0.49(0.36,0.62) |
| Eastern Europe | 960015.55(812,449.81,1,107,581.28) | 1,307,059.27(1,117,925.27,1,496,193.28) | 0.68(0.49,0.88) | 3146.42(3139.78,3153.07) | 3149.95(3144.45,3155.46) | −0.29(−0.56,-0.03) |
| Eastern Sub-Saharan Africa | 71415.39(58,216.51,84,614.26) | 170,987.30(140,609.09,201,365.52) | 2.74(2.61,2.88) | 1407.14(1395.41,1419.03) | 1392.91(1385.90,1399.97) | −0.18(−0.25,-0.12) |
| High-income Asia Pacific | 74803.68(63,598.83,86,008.52) | 201,013.96(168,145.76,233,882.16) | 3.09(2.83,3.35) | 397.03(394.14,399.94) | 344.11(342.45,345.79) | −0.77(−1.08,-0.45) |
| High-income North America | 585847.48(488,874.89,682,820.07) | 403,204.46(354,370.58,452,038.35) | −1.65(−2.04,-1.27) | 1573.45(1569.35,1577.57) | 604.85(602.96,606.75) | −3.47(−3.77,-3.16) |
| North Africa and Middle East | 465047.11(407,319.86,522,774.35) | 1,150,472.42(1,008,880.43,1,292,064.42) | 2.85(2.74,2.96) | 3847.31(3835.69,3858.97) | 3457.04(3450.48,3463.61) | −0.46(−0.52,-0.40) |
| Oceania | 2800.95(2251.44,3350.45) | 7477.49(6106.98,8847.99) | 3.16(3.09,3.23) | 1680.37(1605.10,1760.09) | 1688.90(1646.94,1731.93) | 0.01(−0.02,0.03) |
| South Asia | 922940.98(766,462.01,1,079,419.94) | 2,642,935.68(2,227,612.84,3,058,258.51) | 3.36(3.29,3.43) | 2359.63(2354.33,2364.96) | 2259.62(2256.81,2262.43) | −0.33(−0.41,-0.24) |
| Southeast Asia | 197368.49(168,430.15,226,306.84) | 511,535.89(439,897.41,583,174.36) | 3.05(2.98,3.12) | 1053.75(1048.90,1058.63) | 971.02(968.29,973.75) | −0.26(−0.34,-0.18) |
| Southern Latin America | 44660.21(39,905.73,49,414.68) | 58,541.44(51,700.42,65,382.46) | 0.50(0.21,0.79) | 1064.54(1054.53,1074.64) | 652.40(647.08,657.75) | −1.91(−2.22,-1.59) |
| Southern Sub-Saharan Africa | 42369.75(34,862.69,49,876.82) | 85,941.29(70,566.65,101,315.93) | 2.00(1.86,2.13) | 1793.12(1775.83,1810.59) | 1656.46(1644.95,1668.08) | −0.43(−0.53,-0.32) |
| Tropical Latin America | 49279.38(41,673.52,56,885.23) | 131,817.96(112,132.16,151,503.76) | 3.31(3.21,3.42) | 679.69(673.49,685.96) | 546.70(543.74,549.66) | −0.68(−0.79,-0.57) |
| Western Europe | 644301.85(587,677.96,700,925.73) | 532,668.38(479,874.85,585,461.91) | −0.69(−0.89,-0.49) | 996.10(993.61,998.60) | 492.75(491.35,494.16) | −2.39(−2.56,-2.22) |
| Western Sub-Saharan Africa | 108111.29(89,731.30,126,491.29) | 255,121.37(211,598.78,298,643.96) | 2.69(2.53,2.86) | 1710.51(1699.85,1721.25) | 1781.72(1774.36,1789.12) | 0.06(0.03,0.08) |
Abbreviations: EAPC, estimated annual percentage change; SDI, Socio-demographic Index; UI, uncertainty interval.
Global Age-Stratified Long-Term Trends
Between 1990 and 2021, the absolute DALYs, deaths and incident cases of IHD in women aged ≥55 years rose continuously, with the magnitude of growth increasing with age; the steepest absolute growth occurred in the 90–94 and ≥95-year groups (Figure 3A–C). Age-stratified analysis (Table 4) showed that incidence count grew fastest in women aged ≥95 years (EAPC 4.49), the highest EAPC observed across all age groups. In contrast, the age-stratified DALY and death rates declined in every age band, with the largest relative declines in the oldest groups: the DALY rate among women aged ≥95 years fell by EAPC −2.03 from 77 023.30 to 43 893.93 per 100 000.
Figure 3.
Long-term trends in age-specific rates of ischemic heart disease in women aged 55 years and older globally, 1990–2021. (A) DALY rate per 100 000. (B) Death rate per 100 000. (C) Incidence rate per 100 000.
Table 4.
Counts and Rates of Ischemic Heart Disease in Women Aged 55 years and Older Globally, by Age Group, 1990 and 2021
| Age Group | Count, 1990 (95% UI) | Count, 2021 (95% UI) | EAPC of Count, 1990–2021 (95% CI) |
Rate Per 100 000, 1990 (95% UI) |
Rate Per 100 000, 2021 (95% UI) |
EAPC of Rate, 1990–2021 (95% CI) |
|---|---|---|---|---|---|---|
| DALYs | ||||||
| 55–59 years | 3798681.69(3,533,654.77,4,067,246.21) | 6,029,393.84(5,580,686.17,6,519,976.93) | 1.45(1.25,1.65) | 4115.05(3827.95,4405.98) | 2999.65(2776.41,3243.71) | −1.22(−1.36,-1.09) |
| 60–64 years | 5179713.97(4,899,357.61,5,492,577.03) | 7,156,576.56(6,678,714.51,7,623,700.38) | 1.02(0.78,1.26) | 6311.87(5970.23,6693.11) | 4350.21(4059.74,4634.16) | −1.44(−1.55,-1.34) |
| 65–69 years | 6051666.05(5,756,284.11,6,356,499.81) | 8,901,508.63(8,284,740.20,9,547,342.44) | 0.73(0.47,1.00) | 9130.70(8685.03,9590.63) | 6181.22(5752.94,6629.69) | −1.56(−1.69,-1.43) |
| 70–74 years | 6046288.88(5,701,040.86,6,340,879.38) | 9,341,123.58(8,627,047.71,10,026,943.20) | 0.71(0.47,0.96) | 12,852.78(12,118.88,13,479.00) | 8534.77(7882.34,9161.39) | −1.56(−1.72,-1.41) |
| 75–79 years | 7046560.17(6,609,055.39,7,357,081.34) | 8,381,868.73(7,594,427.78,9,045,153.11) | 1.00(0.78,1.21) | 19,399.89(18,195.39,20,254.78) | 11,625.71(10,533.53,12,545.69) | −1.51(−1.61,-1.41) |
| 80–84 years | 5959420.05(5,380,670.86,6,263,187.90) | 8,842,836.93(7,638,392.63,9,606,626.13) | 1.40(1.17,1.64) | 26,974.87(24,355.21,28,349.85) | 17,362.32(14,997.47,18,861.97) | −1.48(−1.58,-1.37) |
| 85–89 years | 3713028.50(3,184,600.42,3,954,584.59) | 6,308,711.49(5,238,213.77,7,021,475.33) | 1.73(1.53,1.92) | 36,956.55(31,696.99,39,360.80) | 22,159.83(18,399.63,24,663.47) | −1.66(−1.74,-1.59) |
| 90–94 years | 1607033.88(1,319,941.04,1,747,131.06) | 3,878,856.88(3,102,384.89,4,348,398.06) | 2.56(2.32,2.80) | 53,103.55(43,616.72,57,732.98) | 32,160.66(25,722.72,36,053.75) | −1.74(−1.84,-1.65) |
| 95+ years | 583725.14(447,198.73,652,852.38) | 1,728,659.88(1,276,768.41,1,976,584.85) | 3.40(3.30,3.50) | 77,023.30(59,008.46,86,144.73) | 43,893.93(32,419.55,50,189.21) | −2.03(−2.14,-1.91) |
| Deaths | ||||||
| 55–59 years | 111750.37(103,886.86,119,890.14) | 176,069.04(162,151.24,190,958.75) | 1.42(1.22,1.63) | 121.06(112.54,129.88) | 87.60(80.67,95.00) | −1.25(−1.39,-1.11) |
| 60–64 years | 176495.63(166,309.37,187,011.24) | 241,847.50(226,048.75,257,800.99) | 0.99(0.74,1.23) | 215.07(202.66,227.89) | 147.01(137.41,156.71) | −1.48(−1.59,-1.36) |
| 65–69 years | 243827.69(232,001.21,256,465.23) | 355,551.17(329,671.08,380,160.36) | 0.70(0.44,0.96) | 367.88(350.04,386.95) | 246.90(228.92,263.98) | −1.60(−1.73,-1.47) |
| 70–74 years | 296678.87(279,486.66,310,770.84) | 452,873.47(417,779.32,486,933.99) | 0.68(0.43,0.94) | 630.66(594.11,660.62) | 413.78(381.72,444.90) | −1.59(−1.75,-1.43) |
| 75–79 years | 435253.81(407,835.70,454,002.11) | 512,643.95(464,702.43,555,175.46) | 0.98(0.76,1.19) | 1198.30(1122.81,1249.91) | 711.04(644.55,770.03) | −1.53(−1.63,-1.43) |
| 80–84 years | 470368.38(423,605.50,496,108.77) | 695,359.26(600,181.74,755,641.62) | 1.38(1.15,1.62) | 2129.09(1917.42,2245.60) | 1365.29(1178.42,1483.65) | −1.49(−1.60,-1.38) |
| 85–89 years | 369289.28(316,419.32,393,720.74) | 624,204.93(512,049.41,696,799.43) | 1.71(1.51,1.91) | 3675.61(3149.39,3918.78) | 2192.57(1798.61,2447.56) | −1.68(−1.76,-1.59) |
| 90–94 years | 184357.90(150,712.96,200,465.40) | 442,767.12(351,248.42,496,966.20) | 2.55(2.31,2.79) | 6092.00(4980.23,6624.27) | 3671.10(2912.30,4120.48) | −1.76(−1.85,-1.66) |
| 95+ years | 71155.59(54,152.41,79,478.62) | 210,555.21(153,488.45,241,371.79) | 3.42(3.32,3.51) | 9389.07(7145.48,10,487.31) | 5346.39(3897.36,6128.88) | −2.01(−2.12,-1.90) |
| Incidence | ||||||
| 55–59 years | 530504.28(312,586.76,819,675.24) | 1,229,998.41(731,545.22,1,905,419.82) | 2.83(2.67,2.99) | 574.69(338.62,887.94) | 611.93(363.95,947.95) | 0.12(0.08,0.15) |
| 60–64 years | 735010.32(497,549.31,1,039,888.07) | 1,489,026.88(1,001,527.46,2,095,907.05) | 2.32(2.11,2.53) | 895.66(606.30,1267.18) | 905.12(608.79,1274.02) | −0.17(−0.27,-0.08) |
| 65–69 years | 854596.64(523,350.92,1,321,458.92) | 1,786,829.36(1,092,460.43,2,756,567.97) | 1.87(1.61,2.14) | 1289.41(789.63,1993.81) | 1240.78(758.61,1914.16) | −0.45(−0.58,-0.32) |
| 70–74 years | 889416.13(630,949.12,1,227,825.70) | 1,825,977.33(1,271,678.30,2,550,504.44) | 1.67(1.46,1.89) | 1890.66(1341.23,2610.03) | 1668.35(1161.90,2330.34) | −0.62(−0.72,-0.53) |
| 75–79 years | 988421.11(683,841.24,1,395,215.85) | 1,576,680.06(1,049,900.32,2,252,668.35) | 1.81(1.67,1.95) | 2721.22(1882.68,3841.17) | 2186.87(1456.22,3124.47) | −0.72(−0.78,-0.66) |
| 80–84 years | 862027.48(634,630.81,1,125,132.62) | 1,622,235.72(1,173,445.33,2,145,787.67) | 2.11(1.89,2.33) | 3901.90(2872.61,5092.83) | 3185.15(2303.98,4213.11) | −0.79(−0.90,-0.67) |
| 85–89 years | 542910.84(376,075.36,775,225.85) | 1,198,476.16(812,433.11,1,713,329.30) | 2.47(2.21,2.73) | 5403.70(3743.16,7715.98) | 4209.74(2853.73,6018.20) | −0.94(−1.08,-0.81) |
| 90–94 years | 214697.55(153,220.67,279,645.57) | 680,596.39(483,225.61,887,443.22) | 3.41(3.09,3.73) | 7094.56(5063.09,9240.73) | 5643.01(4006.56,7358.03) | −0.93(−1.15,-0.71) |
| 95+ years | 71225.15(44,626.20,113,892.45) | 276,482.11(176,154.05,424,234.74) | 4.49(4.27,4.70) | 9398.25(5888.49,15,028.26) | 7020.40(4472.88,10,772.12) | −1.00(−1.27,-0.73) |
Abbreviations: DALY, disability-adjusted life-years; EAPC, estimated annual percentage change; UI, uncertainty interval.
Regional and Country Rankings by Burden and EAPC
In 2021, the regions with the highest age-standardized DALY, death and incidence rates in women aged ≥55 years were consistently Central Asia, Eastern Europe and North Africa and the Middle East, while the lowest were the high-income Asia Pacific, Australasia and Western Europe (Figure 4A and Table 5). The regions with the greatest absolute growth in case numbers were East Asia, South Asia and Eastern Europe, while the smallest absolute growth was seen in Oceania, Australasia and Andean Latin America. Ranking by EAPC, the largest increases in age-standardized DALY rate occurred in southern sub-Saharan Africa (0.65), East Asia (0.23), and South Asia (0.00), while the largest decreases occurred in Western Europe (−4.46), Australasia (−5.27), and the high-income Asia Pacific (−3.83) (Figure 4B and Table 5).
Figure 4.
Age-standardized DALY, death and incidence rates and corresponding EAPCs of ischemic heart disease in women aged 55 years and older across the 21 GBD regions, 2021. (A) Age-standardized DALY, death and incidence rates. (B) EAPCs of age-standardized DALY, death and incidence rates, 1990–2021.
Table 5.
Top Three and Bottom Three Regions and Countries of Ischemic Heart Disease Burden in Women Aged 55 years and Older
| Measure | Top Region 1 | Top Region 2 | Top Region 3 | Bottom Region 1 | Bottom Region 2 | Bottom Region 3 | Top Country 1 | Top Country 2 | Top Country 3 | Bottom Country 1 | Bottom Country 2 | Bottom Country 3 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Measure | Top three regions | Bottom three regions | Top three countries | Bottom three countries | ||||||||
| ASR 2021 | ||||||||||||
| Age standardized DALY rate | North Africa and Middle East(16239.37) | Eastern Europe(17690.80) | Central Asia(19862.64) | High-income Asia Pacific(1359.50) | Australasia(2469.28) | Western Europe(2590.61) | Nauru(30629.15) | United Arab Emirates(37470.17) | Egypt(38314.66) | Japan(1290.05) | France(1572.61) | San Marino(1590.06) |
| ASDR | North Africa and Middle East(1012.07) | Eastern Europe(1179.12) | Central Asia(1257.61) | High-income Asia Pacific(95.68) | Australasia(183.87) | Western Europe(184.71) | Syrian Arab Republic(1918.71) | United Arab Emirates(2474.40) | Egypt(2641.83) | Japan(89.18) | San Marino(107.51) | France(110.11) |
| ASIR | Eastern Europe(3149.95) | North Africa and Middle East(3457.04) | Central Asia(3739.27) | High-income Asia Pacific(344.11) | Western Europe(492.75) | Tropical Latin America(546.70) | Egypt(4697.27) | Syrian Arab Republic(4798.83) | Uzbekistan(6098.77) | Portugal(204.84) | Malta(311.31) | Luxembourg(327.67) |
| Case number increase times | ||||||||||||
| DALY | Eastern Europe(7325352.13) | East Asia(13087178.04) | South Asia(13272271.17) | Oceania(67050.43) | Australasia(146277.11) | Andean Latin America(213584.70) | Russian Federation(4147586.03) | India(10886638.09) | Chile(12720850.14) | Tokelau(21.34) | Niue(32.38) | San Marino(137.71) |
| Death | Eastern Europe(501108.97) | South Asia(657074.29) | East Asia(860243.77) | Oceania(3124.75) | Australasia(11925.65) | Andean Latin America(13496.89) | Russian Federation(279817.71) | India(538963.13) | Chile(837342.94) | Tokelau(1.25) | Niue(1.97) | Nauru(6.47) |
| Incidence | Eastern Europe(1307059.27) | South Asia(2642935.68) | East Asia(3138776.06) | Oceania(7477.49) | Australasia(46468.83) | Andean Latin America(46658.99) | Russian Federation(901931.04) | India(2210025.55) | Chile(3034283.61) | Tokelau(2.28) | Niue(3.64) | Nauru(7.61) |
| EAPC 1990-2021 | ||||||||||||
| Age standardized DALY rate | Southern sub-Saharan Africa(3.13) | South Asia(3.55) | East Asia(3.79) | Western Europe(−2.60) | Australasia(−2.35) | High-income North America(−1.51) | Djibouti(5.28) | Honduras(5.34) | Northern Mariana Islands(5.43) | Denmark(−5.22) | Georgia(−4.59) | United Kingdom(−4.23) |
| ASDR | Central Latin America(3.41) | South Asia(3.93) | East Asia(4.60) | Western Europe(−2.03) | Australasia(−1.62) | High-income North America(−1.42) | Honduras(5.21) | Northern Mariana Islands(5.31) | Djibouti(5.40) | Denmark(−4.91) | Georgia(−4.02) | United Kingdom(−3.75) |
| ASIR | Andean Latin America(3.57) | Central Latin America(3.66) | East Asia(4.17) | High-income North America(−1.65) | Western Europe(−0.69) | Central Europe(−0.09) | Timor-Leste(5.56) | Guam(5.56) | Qatar(7.34) | United States of America(−1.83) | Poland(−1.67) | Germany(−1.54) |
Abbreviations: ASR, age-standardized rate; DALY, disability-adjusted life-years; ASDR, age-standardized death rate; ASIR, age-standardized incidence rate; EAPC, estimated annual percentage change.
At the country level, Egypt, the United Arab Emirates and Nauru had the highest age-standardized DALY rates, whereas Japan, France and San Marino had the lowest (Supplementary Table S2). Djibouti, Honduras and the Northern Mariana Islands had the largest rises in age-standardized DALY rate, whereas Denmark, the United Kingdom and Georgia had the largest declines (Table 5 and Supplementary Table S3).
Discussion
Using the GBD 2021 framework, this study delineated the global, regional and national burden of IHD in women aged 55 years and older across 204 countries from 1990 to 2021 using three complementary indicators—DALYs, deaths and incidence—and the EAPC. We found that the absolute number of DALYs, deaths and incident cases in this population has grown continuously over the past three decades, even as age-standardized rates have declined globally. The burden was spatially heterogeneous, concentrated in Central Asia, Eastern Europe and North Africa and the Middle East, and was lowest in high-income regions. This geographic contrast was substantial, with the highest-burden regions experiencing markedly greater age-standardized rates than the lowest-burden regions. Disease intensity rose steeply with age, with women aged ≥85 years bearing the greatest burden, while the incidence trend was most pronounced among women aged ≥95 years (EAPC 4.49). Meanwhile, several high-income regions showed marked declines in age-standardized burden, with the largest reductions observed in Western Europe, Australasia and the high-income Asia Pacific. High-SDI regions achieved the largest age-standardized declines, whereas low- and middle-SDI regions showed rapidly rising absolute counts and only modest declines in standardized rates. The distinctive contribution of this study is its focused characterization of IHD burden in older women, revealing how demographic aging and unequal progress in cardiovascular control have produced divergent patterns in absolute and age-standardized burden. This perspective helps identify population groups and settings in which the growing absolute burden may be masked by declining standardized rates.
The divergence between rising absolute burden and falling age-standardized rates is consistent with previous global cardiovascular reports4,5,7 and reflects the combined effects of demographic transition, persistent risk-factor exposure and improving medical care. The proportion of women surviving into older ages has expanded substantially since 1990,8 directly amplifying the denominator at risk and producing larger absolute case counts even when intensity per person-year falls. At the same time, scaled-up blood-pressure screening, statin use, smoking control, timely reperfusion and secondary-prevention pharmacotherapy have reduced age-adjusted case fatality and disability in high-income settings,4,5,11,18,19 producing the steeply negative EAPCs observed for Western Europe, Australasia and high-income North America. The pattern reinforces the principle that an effective, fully implemented cardiovascular prevention system can reverse the trajectory of IHD burden even in the face of demographic aging.5,6,20,21
The persistent geographic inequalities and the SDI gradient we observed echo the long-recognized epidemiological transition in cardiovascular disease, in which high-income countries entered a sustained period of mortality decline two to three decades ago while low- and middle-income countries are still in the rising phase.4,5,22,23 In Central Asia and Eastern Europe—regions with documented high prevalence of hypertension, dyslipidemia, harmful alcohol use and historically weaker primary prevention infrastructure4,18—older women bear the heaviest burden. East Asia, South Asia and parts of sub-Saharan Africa, by contrast, are experiencing rapid population aging together with rising prevalence of obesity, diabetes and physical inactivity, low awareness, treatment and control rates of hypertension, and limited access to acute coronary intervention.10,18,22 The observation that absolute case counts in low- and low-middle-SDI regions rose despite gradual declines in age-standardized rates underscores that economic development by itself does not guarantee improvements in cardiovascular outcomes; without targeted investment in prevention, primary care and equitable access to acute and chronic cardiovascular services, the IHD trajectory in these regions will remain unfavorable.5,6,24,25
Our age-stratified findings reinforce that women aged 55 years and older are a particularly vulnerable population. The post-menopausal loss of estrogenic vascular protection is accompanied by adverse changes in lipid profile, endothelial function, fat distribution and glucose metabolism, with consequent increases in coronary atherosclerosis, microvascular disease and ischemic events.9,12,26,27 During the menopausal transition, declining ovarian function is also accompanied by greater visceral adiposity, worsening insulin sensitivity, higher blood pressure and a more atherogenic lipid profile, which may act together to accelerate vascular injury rather than through a single pathway.9,27 Endothelial dysfunction and increasing arterial stiffness may further impair vascular homeostasis and amplify the effects of these metabolic changes, providing a biological link between menopause-related cardiometabolic remodeling and the higher IHD burden observed after menopause.28,29 Older women also more frequently present with atypical symptoms—fatigue, dyspnea, syncope, epigastric or jaw discomfort—rather than classic chest pain,13,30 contributing to delayed diagnosis, undertreatment and worse outcomes.6,18,31,32 Multimorbidity, frailty and polypharmacy further complicate management in women aged ≥75 years, and the very high DALY and death rates we observed in women aged ≥85 and ≥95 years match clinical observations that the oldest old are disproportionately affected by ischemic events and recurrent admissions.8,12,33 The rapidly rising incidence EAPC of 4.49 in women aged ≥95 years signals that the absolute frontier of IHD is shifting into the extreme-elderly range, a group seldom included in randomized trials and underrepresented in clinical guidelines.6,32,33
These findings carry direct implications for policy and practice. First, women aged ≥55 years should be explicitly defined as a priority population within national cardiovascular non-communicable disease strategies, with sex- and age-disaggregated targets for DALY, mortality and incidence reductions aligned with World Health Organization global action plans and Sustainable Development Goal 3.4.24,34 Second, the wide gap between high- and low-SDI regions argues for a tiered response: high-income countries should consolidate their gains by focusing on residual risk in the oldest age groups and on disparities within marginalized subpopulations, while high-burden regions such as Central Asia, Eastern Europe, North Africa and the Middle East should prioritize hypertension and lipid control, smoking cessation, accessible acute care including primary percutaneous coronary intervention, and structured secondary prevention.4,6,10,21 Third, rising-trend regions in East and South Asia and sub-Saharan Africa need urgent expansion of primary care, population-level interventions such as salt reduction and tobacco control, and sex-sensitive risk screening of post-menopausal women.10,20 International collaboration anchored on the 204-country comparability that GBD provides offers a foundation for shared surveillance, technology transfer and aid allocation that explicitly accounts for sex, age and region.1,4,24 Importantly, healthcare planning should not rely solely on declining age-standardized rates, because the substantial increase in absolute cases indicates a growing demand for prevention, diagnosis, treatment, rehabilitation and long-term care among older women. Resource allocation should therefore incorporate population size and age structure alongside standardized rates, with greater emphasis on primary care, cardiovascular risk screening, medication management and integrated geriatric-cardiovascular services in rapidly aging and high-burden settings. Such an approach may better align health-system capacity with the actual number of women requiring care.
Several strengths support these inferences. The analysis used the largest and most comprehensive global cardiovascular dataset available—GBD 2021—covering 1990 to 2021 across 204 countries and 21 regions, and examined three complementary indicators (DALY, death and incidence) rather than relying on mortality alone, thus capturing fatal and non-fatal burden simultaneously and avoiding the bias of any single metric. Burden was stratified into nine five-year age bands from 55–59 through ≥95 years, providing unusually high age resolution in a population that is rarely disaggregated in published cardiovascular epidemiology. Long-term EAPC summarized the direction and magnitude of trend by region and SDI quintile, enabling identification of inflection points, high-growth groups and high-risk geographies, and the analysis followed the GATHER reporting standard.17 Several limitations must also be acknowledged. First, GBD estimates are modeled rather than directly observed and therefore are subject to uncertainty arising from the underlying estimation framework and input data. The availability, completeness, and quality of source data vary substantially across countries, particularly where vital registration and disease surveillance systems are less developed. Such heterogeneity may affect the precision of estimates and their comparability across locations, and may also influence the interpretation of country-level differences and long-term trends. Although GBD reports 95% uncertainty intervals to reflect estimation uncertainty, these intervals may not fully capture all sources of heterogeneity in the underlying data. Second, we did not perform formal attribution of the observed trends to specific behavioral, metabolic, environmental or health-system drivers, nor did we examine sex-specific differences in healthcare access, cultural norms or social support that likely shape the observed disparities. Third, the analysis treated IHD as a single composite cause and could not distinguish trends in clinical subtypes such as stable angina, acute myocardial infarction or ischemic cardiomyopathy, which may follow different epidemiological trajectories. Fourth, this is an observational descriptive study based on population-level estimates and cannot establish causal relationships; associations between SDI, region and burden are ecological. Future work integrating individual-level cohort data, sex- and age-stratified risk-factor attribution and evaluation of policy interventions will be necessary to translate the patterns reported here into actionable, context-specific prevention strategies.
Conclusion
Between 1990 and 2021, the global burden of IHD in women aged 55 years and older was characterized by continued growth in absolute DALYs, deaths and incident cases, modest but sustained declines in age-standardized rates, and pronounced regional and age-specific disparities. Population aging, persistent exposure to cardiometabolic risk factors and uneven implementation of prevention and control were the principal drivers, while high-income regions demonstrated that comprehensive, sex-sensitive and life-course-oriented strategies can effectively reduce burden. Older women should be prioritized in cardiovascular prevention and public health planning, with age- and sex-specific screening, risk-factor control and equitable access to evidence-based care, while health resources should be preferentially directed toward high-burden and rapidly rising regions to address persistent geographic inequalities.
Data Sharing Statement
This study was a population-based, cross-country descriptive analysis of routinely modeled estimates from the GBD Study 2021. (http://ghdx.healthdata.org/gbd-results-tool).
Ethics Approval
Since this study was a secondary-analysis based on publicly available aggregated population-level data from the Global Burden of Disease Study 2021 without access to any individual-level human participant information, it was exempted from ethical approval in accordance with Items 1 and 2, Article 32 of the Measures for Ethical Review of Life Science and Medical Research Involving Human Subjects, issued on February 18, 2023, China.
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 author(s) of this work have nothing to disclose.
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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
This study was a population-based, cross-country descriptive analysis of routinely modeled estimates from the GBD Study 2021. (http://ghdx.healthdata.org/gbd-results-tool).