Abstract
Background: Ischemic heart disease (IHD) is a leading cause of death in Iran, and monitoring its trends is essential for disease management and achieving Sustainable Development Goal 3.4. Methods: This study examines the prevalence of IHD in Iran at national and subnational levels and projects future trends to 2040. We retrieved sex-specific IHD data for Iran and its provinces from 1990 to 2021 from the Global Burden of Disease (GBD) Study 2021 and applied the illness-death model (IDM) to estimate age-standardized prevalence rates (ASPRs) by 2040. Results: In Iran, the ASPR of IHD decreased until 2009 but began to rise again by 2021. By 2040, prevalence is projected to increase by 16% to 7,336.1 per 100,000 (95% CI: 7,163.9-7,512.4). In 2021, the highest provincial ASPRs were observed in Khuzestan, Yazd, and Alborz; by 2040, Yazd, Khuzestan, and North Khorasan are expected to have the highest rates. Conversely, Hamadan, Sistan and Baluchistan, and West Azarbayejan had the lowest ASPRs in both 2021 and 2040. A similar pattern was observed in both males and females. Conclusion: These findings indicate an upward trend in IHD nationwide and across all provinces by 2040. To lessen the future impact of IHD in Iran, it is crucial to tackle modifiable risk factors, strengthen the healthcare system, and improve prevention efforts.
Keywords: Ischemic heart disease (IHD), Iran, global burden of disease (GBD), illness death model (IDM)
Introduction
Cardiovascular diseases (CVDs) have remained the leading cause of death in most regions of the world over the past decades [1]. While high-income countries have experienced a decrease in cardiovascular disease (CVD) mortality, low- and middle-income countries, particularly in the Eastern Mediterranean Region (EMR), continue to face high CVD mortality rates. On the another hands, ischemic heart disease (IHD) is the most common type of CVD, responsible for approximately 16% of global deaths in 2019, equivalent to approximately 9.14 million deaths [2]. In this setting, highest burdens of CVD has been reported in the North Africa and Middle East (NAME) region [2,3], with Iran reporting the highest age-standardized prevalence rate (ASPR) in 2019 [4]. So that in that year, Iran’s age-adjusted mortality, disability-adjusted life years (DALYs), and prevalence rates of IHD were 163.6, 2842.7, and 6198.5 per 100,000 people, respectively [5]. Hence, understanding the epidemiology of cardiovascular diseases, including the current status and future picture, is crucial for health planning.
On the other hand, IHD imposes lifelong costs on health systems due to its chronic nature [6,7], making it essential for countries, including Iran, to monitor and forecast its burden as the leading cause of non-communicable disease (NCD) mortality. This aligns with Sustainable Development Goal 3.4, which aims to reduce premature mortality from NCDs by one-third by 2030 [8]. Moreover, epidemiological evidence have demonstrated the substantial influence of some demographic factors on IHD, such that men exhibit a higher incidence than women, particularly in younger age groups [9], which is linked to biological factors, such as estrogen’s protective effect in premenopausal women, as well as behavioral and environmental factors, such as higher smoking, alcohol consumption, and physical inactivity [10]. The risk for women significantly increases after menopause, often surpassing that for men [11]. Age also plays a crucial role in IHD development and progression [12], with incidence rates generally rising due to cumulative risk factors, such as hypertension, diabetes, hyperlipidemia, smoking, and sedentary lifestyles [13]. Therefore, a comprehensive understanding of IHD epidemiology must consider sex and age differences.
Overall, accurate assessment and prediction of the burden of CVD at national and regional levels is crucial for effective implementation of health policies and reduction of healthcare costs. In this context, we aim to report the ASPR of IHD in Iran and its provinces from 1990 to 2021 and to predict its prevalence until 2040 using the illness-death model (IDM) (IDM) stratified by sex and age.
Materials and methods
Data source
To forecast the future prevalence of ischemic heart disease (IHD) in Iran and its provinces, we employed a dynamic simulation model, IDM. We sourced epidemiological metrics, including prevalence, incidence, and mortality rates, from the Global Health Data Exchange (GHDx) query tool for the years 1990 to 2021, stratified by sex at both national and subnational level at https://vizhub.healthdata.org/gbd-results/. Additionally, we obtained population forecast data from https://amar.org.ir/population-and-migration. These comprehensive datasets provide the crucial parameters required to develop predictive models for IHD’s future prevalence of IHD in Iran. In other words, the data used in this study is based on GBD methodology which is updated after each GBD report. Briefly, GBD for each disease applies a systematic review to collect disease-related health metrics by considering multiple sources of data, such as vital data, verbal autopsy, registries, population-based surveys, and literature. Accordingly, all identified data are assessed for quality. Studies were eligible if they provided age- and sex-specific estimates using clearly defined and standardized case definitions and ICD-coded cause-of-death data, while sources with non-representative sampling, data without age, sex, and location information, inadequate sample size, duplicate data, or unclear or non-validated diagnostic criteria or case definitions were excluded.
Statistical analysis
Modeling
Modeling framework and projection methodology
To forecast the future prevalence of IHD across Iran and its provinces, we implemented a discrete-time illness-death model (IDM). This compartmental model stratifies the population into three mutually exclusive states: (1) Susceptible (S), individuals at risk without IHD; (2) Ill (I), individuals with active IHD; and (3) Dead (D), an absorbing state. The structure and permitted transitions between these states are illustrated in Figure 1. While a comprehensive technical exposition of the IDM framework is available elsewhere [14], we provide a concise description of our specific implementation below.
Figure 1.
Illness-death model for ischemic heart disease.
Discrete-time model equations
The core dynamics of the model are defined by the following system of discrete-time difference equations, which govern the annual transition of individuals between health states from year t to t+1:
St+1 = -θ01St - θ02St
It+1 = +θ01St - θ12It
Here, St and It represent the number of individuals in the Susceptible and Ill states at the beginning of year t. Our model parameters are defined as annual transition rates: θ01: The incidence rate, representing the rates that a susceptible individual develops IHD within one year. θ02: The background mortality rate, representing the probability that a susceptible individual dies from a cause other than IHD within one year. θ12: The excess mortality rate, representing the probability that an individual with IHD dies from any cause within one year.
Demographic stratification and model calibration
To account for essential epidemiological heterogeneity, the model was stratified and calibrated independently for each combination of sex, age group (<45 and ≥45 years), and geographic unit (national and provincial levels). This allows for distinct sets of transition probabilities across key demographic and regional subgroups. To estimate the time-varying parameters θ01, θ02, and θ12 for each demographic and geographic stratum, we fitted cubic spline regressions to the corresponding historical GBD data from 1990 to 2021. The optimal spline for each parameter was determined by minimizing the sum of least squares between the smoothed curve and the annual GBD estimates over the 32-year calibration period, yielding a complete annual series for each transition probability. These fitted splines were then extrapolated to provide parameter estimates through 2040. The projected annual parameters were subsequently integrated into the discrete-time model equations to simulate IHD prevalence from 2022 to 2040. The complete technical details and R code for this spline fitting and model integration process are provided in the referenced methodological paper [14]. All analyses and projections were conducted using R statistical software (version 4.3.1). Data are presented as ASPRs per 100,000 population with corresponding 95% confidence intervals (95% CIs). The study employed a descriptive epidemiological modeling approach based on the IDM. Temporal trends were summarized by calculating percentage changes in ASPRs for the periods 1990-2021 and 2021-2040. As the primary objective was to describe and project disease burden rather than test predefined hypotheses, no formal inferential statistical comparisons were performed; consequently, p-values and significance thresholds were not applicable.
Results
Historical trend: 1990 to 2021
In Iran, the Age-Standardized Prevalence Rate (ASPR) of IHD has shown a decreasing trend until 2009, followed by an increase by 2021. However, the ASPR in 1990 was higher than that in 2021 (6496.75 per 100,000 individuals vs. 6327.23 per 100,000 individuals) (Figure 2). Furthermore, a distinct geographic pattern emerged, with the highest IHD burdens consistently concentrated in the southern and central provinces - such as Khuzestan, Yazd, and Kerman - while the western and northwestern regions, including Hamadan and West Azarbayejan, recorded the lowest rates. This spatial disparity persisted over the three decades; for instance, while Kerman and Isfahan led in prevalence in 1990, Khuzestan assumed the highest burden by 2021 (6,915.60 per 100,000), followed by Yazd and Alborz. Conversely, Hamadan, West Azarbayejan, and Sistan and Baluchistan remained the provinces with the lowest prevalence in 2021 (Table 1; Figures 3, 4 and 5). Additionally, beyond static burden, the rate of change varied significantly by region. Central and southern provinces experienced the most rapid increases, with Yazd (4.86%), Semnan (3.79%), and Khuzestan (3.23%) showing the highest percentage growth, suggesting a worsening epidemiological transition in these areas. In contrast, provinces like Isfahan, Tehran, and Sistan and Baluchistan demonstrated more stable trends (Table 1). These geographic and temporal patterns were consistent across both sexes, with females and males reflecting similar regional distributions of high and low ASPRs, and experiencing the most significant increases in Khuzestan, Yazd, and Semnan (Tables 2, 3; Figures 3, 4 and 5). Consequently, effective IHD management in Iran requires moving away from uniform national policies. Strategies must instead be localized to tackle regional disparities and the rising burden in high-risk provinces.
Figure 2.
Age-standardized prevalence rates (ASPR) of ischemic heart disease (IHD) per 100,000 population in Iran, reported for males, females, and the overall population, were analyzed for the period 1990-2021 and projected for 2021-2040. The halo effect in each scatter plot illustrates the 95% confidence intervals surrounding the estimated values.
Table 1.
Estimated age-standardized prevalence rates (ASPR) of ischemic heart disease (IHD) per 100,000 population, with 95% confidence intervals, reported every 5 years from 2022 to 2040, alongside the percentage changes in ASPR for 1990-2021 and 2021-2040, across Iran and its 31 provinces for the overall population
| ASPR, 2022 | ASPR, 2025 | ASPR, 2030 | ASPR, 2035 | ASPR, 2040 | Percentage change (1990-2021) | Percentage change (2021-2040) | |
|---|---|---|---|---|---|---|---|
| Iran (Islamic Republic of) | 6373.613 (6340.376-6407.025) | 6524.621 (6471.473-6578.207) | 6784.428 (6694.736-6875.329) | 7054.764 (6925.356-7186.61) | 7336.073 (7163.913-7512.41) | -2.60931 | 15.94454 |
| Alborz | 6767.493 (6723.916-6811.352) | 6883.73 (6814.594-6953.568) | 7083.143 (6967.925-7200.264) | 7289.549 (7125.285-7457.587) | 7502.887 (7286.863-7725.285) | 1.925215 | 11.19603 |
| Ardebil | 6570.965 (6535.93-6606.189) | 6687.877 (6632.217-6744.004) | 6887.43 (6794.465-6981.666) | 7093.016 (6960.239-7228.325) | 7304.823 (7129.957-7483.976) | 1.539665 | 11.82165 |
| Bushehr | 6603.665 (6566.924-6640.612) | 6734.773 (6676.322-6793.734) | 6959.135 (6861.224-7058.435) | 7191.022 (7050.743-7334.071) | 7430.689 (7245.353-7620.727) | 0.514821 | 13.46218 |
| Chahar Mahaal and Bakhtiari | 6378.137 (6351.593-6404.793) | 6486.142 (6443.97-6528.59) | 6670.233 (6599.83-6741.387) | 6859.553 (6759.068-6961.533) | 7054.25 (6922.011-7189.019) | -2.29716 | 11.40743 |
| East Azarbayejan | 6402.331 (6371.255-6433.559) | 6579.469 (6529.613-6629.706) | 6885.767 (6801.118-6971.467) | 7206.472 (7083.57-7331.5) | 7542.276 (7377.731-7710.478) | -0.72256 | 18.96262 |
| Fars | 6189.095 (6157.303-6221.052) | 6342.45 (6291.49-6393.825) | 6606.572 (6520.354-6693.941) | 6881.744 (6757.1-7008.715) | 7168.432 (7002.313-7338.545) | -5.35197 | 16.91089 |
| Gilan | 6470.922 (6432.567-6509.508) | 6609.557 (6548.526-6671.165) | 6847.793 (6745.604-6951.539) | 7095.235 (6948.832-7244.687) | 7352.169 (7158.631-7550.779) | -0.5813 | 14.29488 |
| Golestan | 6685.005 (6647.428-6722.795) | 6847.903 (6787.777-6908.563) | 7128.346 (7026.784-7231.38) | 7420.376 (7273.714-7570.007) | 7724.479 (7529.202-7924.845) | -0.09862 | 16.37833 |
| Hamadan | 5900.589 (5872.9-5928.409) | 6016.967 (5972.857-6061.403) | 6216.116 (6142.15-6290.976) | 6421.943 (6315.907-6529.766) | 6634.676 (6494.517-6777.872) | -1.89924 | 13.81666 |
| Hormozgan | 6496.689 (6463.47-6530.079) | 6657.276 (6604.113-6710.867) | 6933.383 (6843.529-7024.416) | 7220.536 (7090.699-7352.749) | 7519.281 (7346.306-7696.328) | -0.03759 | 16.87608 |
| Ilam | 6399.007 (6367.126-6431.048) | 6538.935 (6487.965-6590.312) | 6779.185 (6693.407-6866.089) | 7028.508 (6905.185-7154.093) | 7287.235 (7123.781-7454.539) | -0.91784 | 14.84848 |
| Isfahan | 6377.553 (6336.711-6418.659) | 6503.737 (6438.772-6569.354) | 6719.786 (6611.009-6830.343) | 6943.23 (6787.45-7102.563) | 7174.325 (6968.591-7386.091) | -6.80102 | 12.98597 |
| Kerman | 6480.044 (6435.602-6524.795) | 6661.075 (6589.71-6733.224) | 6974.119 (6852.935-7097.495) | 7301.903 (7126.019-7482.243) | 7645.125 (7409.776-7888.161) | -5.59442 | 18.85504 |
| Kermanshah | 6392.143 (6352.394-6432.14) | 6519.501 (6456.189-6583.433) | 6737.393 (6631.272-6845.213) | 6962.536 (6810.474-7117.995) | 7195.184 (6994.288-7401.856) | -1.26709 | 13.12082 |
| Khorasan-e-Razavi | 6440.079 (6401.547-6478.843) | 6636.391 (6574.472-6698.892) | 6977.362 (6871.906-7084.427) | 7336.368 (7182.742-7493.251) | 7714.384 (7507.983-7926.397) | -4.39661 | 20.73708 |
| Khuzestan | 6969.218 (6929.177-7009.49) | 7152.457 (7088.293-7217.201) | 7468.754 (7360.081-7579.031) | 7799.193 (7641.824-7959.802) | 8144.4 (7934.275-8360.089) | 3.227561 | 17.7685 |
| Kohgiluyeh and Boyer-Ahmad | 6264.774 (6233.878-6295.824) | 6429.402 (6379.86-6479.33) | 6713.486 (6629.519-6798.524) | 7010.17 (6888.51-7133.995) | 7320.012 (7157.489-7486.259) | -0.66424 | 18.76956 |
| Kurdistan | 6248.461 (6220.575-6276.471) | 6387.427 (6342.99-6432.17) | 6626.066 (6551.357-6701.605) | 6873.799 (6766.33-6982.92) | 7130.997 (6988.415-7276.38) | -1.75291 | 15.10266 |
| Lorestan | 6375.667(6344.284-6407.204) | 6507.408 (6457.521-6557.674) | 6733.127 (6649.524-6817.757) | 6966.778 (6846.861-7088.734) | 7208.647 (7049.995-7370.755) | -2.51558 | 14.10948 |
| Markazi | 6512.917 (6478.156-6547.865) | 6679.576 (6623.914-6735.705) | 6967.051 (6872.865-7062.527) | 7267.144 (7130.864-7406.023) | 7580.43 (7398.605-7766.717) | 0.404911 | 17.34133 |
| Mazandaran | 6623.342 (6584.956-6661.951) | 6749.713 (6688.625-6811.359) | 6964.891 (6862.62-7068.685) | 7186.167 (7039.81-7335.569) | 7413.957 (7220.862-7612.217) | -0.20043 | 12.36564 |
| North Khorasan | 6648.754 (6615.095-6682.584) | 6818.992 (6765.077-6873.34) | 7112.64 (7021.402-7205.073) | 7419.163 (7287.16-7553.578) | 7739.141 (7563.038-7919.377) | 2.01188 | 17.44535 |
| Qazvin | 6118.917 (6090.06-6147.91) | 6241.877 (6195.886-6288.21) | 6452.347 (6375.174-6530.457) | 6669.947 (6559.242-6782.528) | 6894.927 (6748.505-7044.539) | 0.511746 | 13.71537 |
| Qom | 6391.913 (6361.614-6422.357) | 6557.455 (6508.802-6606.476) | 6846.06 (6763.261-6929.898) | 7153.466 (7032.623-7276.481) | 7484.653 (7321.247-7651.987) | -0.14941 | 18.65778 |
| Semnan | 6686.683 (6646.404-6727.207) | 6807.065 (6743.078-6871.659) | 7012.603 (6905.74-7121.116) | 7224.437 (7071.826-7380.33) | 7442.765 (7241.799-7649.284) | 3.789485 | 11.91153 |
| Sistan and Baluchistan | 5910.885 (5879.695-5942.241) | 6031.392 (5981.706-6081.491) | 6237.872 (6154.522-6322.351) | 6451.625 (6332.063-6573.442) | 6672.924 (6514.778-6834.904) | -5.9446 | 13.68662 |
| South Khorasan | 6241.607 (6214.438-6268.894) | 6389.199 (6345.777-6432.918) | 6643.242 (6569.966-6717.333) | 6907.57 (6801.813-7014.964) | 7182.511 (7041.76-7326.063) | -3.70091 | 16.42857 |
| Tehran | 6177.975 (6145.194-6210.931) | 6336.055 (6283.569-6388.978) | 6608.81 (6520.007-6698.819) | 6893.655 (6765.174-7024.568) | 7191.166 (7019.753-7366.753) | -5.94462 | 17.20625 |
| West Azarbayejan | 5922.308 (5896.328-5948.401) | 6056.613 (6015.157-6098.352) | 6287.32 (6217.526-6357.891) | 6526.902 (6426.397-6628.961) | 6775.707 (6642.241-6911.82) | -3.30175 | 15.56726 |
| Yazd | 6887.31 (6851.527-6923.28) | 7115.303 (7057.659-7173.415) | 7511.404 (7412.881-7611.219) | 7928.241 (7784.318-8074.767) | 8366.393 (8172.678-8564.56) | 4.856239 | 23.0966 |
| Zanjan | 6265.947 (6233.869-6298.192) | 6360.743 (6309.865-6412.044) | 6521.888 (6437.24-6607.7) | 6687.072 (6566.688-6809.769) | 6856.412 (6698.556-7018.162) | -2.8401 | 10.14064 |
Figure 3.
Age-standardized prevalence rates (ASPR) of ischemic heart disease (IHD) per 100,000 population in Iran’s 31 provinces, shown for males (blue), females (green), and both sexes (red), from 1990 to 2021 and projected through 2040, with halo effects representing 95% confidence intervals.
Figure 4.
The lollipop plot depicts the percentage changes in ASPR for both sexes (A), females (B), and males (C) across Iran and its 31 provinces, comparing the periods 1990-2021 and 2021-2040. Each line reflects the variations in ASPR over these two timeframes.
Figure 5.
Map of age-standardized prevalence rates (ASPR) of ischemic heart disease (IHD) in 2021 and 2040 across 31 provinces of Iran.
Table 2.
The estimated age-standardized prevalence rates (ASPR) of ischemic heart disease (IHD) per 100,000 population in females, including 95% confidence intervals, are presented at 5-year intervals from 2022 to 2040, alongside the percentage changes in IHD prevalence for the periods 1990-2021 and 2021-2040 across Iran and its 31 provinces
| ASPR, 2022 | ASPR, 2025 | ASPR, 2030 | ASPR, 2035 | ASPR, 2040 | Percentage change (1990-2021) | Percentage change (2021-2040) | |
|---|---|---|---|---|---|---|---|
| Iran (Islamic Republic of) | 5325.38 (5296.014-5354.909) | 5459.615 (5412.622-5507.016) | 5691.023 (5611.578-5771.594) | 5932.407 (5817.553-6049.529) | 6184.214 (6031.1-6341.217) | -1.82931 | 16.36103 |
| Alborz | 5672.703 (5631.709-5713.995) | 5799.565 (5734.178-5865.698) | 6017.429 (5907.516-6129.389) | 6243.594 (6085.613-6405.678) | 6478.378 (6268.997-6694.753) | 2.057556 | 13.97336 |
| Ardebil | 5521.654 (5490.964-5552.515) | 5636.665 (5587.814-5685.941) | 5833.771 (5751.842-5916.856) | 6037.866 (5920.332-6157.707) | 6249.209 (6093.714-6408.619) | 3.680954 | 13.2987 |
| Bushehr | 5509.921 (5482.208-5537.774) | 5639.064 (5594.822-5683.655) | 5861.126 (5786.571-5936.636) | 6092.016 (5984.553-6201.395) | 6332.091 (6189.247-6478.206) | 0.842005 | 15.38693 |
| Chahar Mahaal and Bakhtiari | 5346.313 (5322.44-5370.292) | 5444.273 (5406.339-5482.473) | 5611.566 (5548.148-5675.706) | 5784.027 (5693.349-5876.139) | 5961.816 (5842.254-6083.806) | -1.26143 | 11.7634 |
| East Azarbayejan | 5353.298 (5327.19-5379.535) | 5508.408 (5466.494-5550.642) | 5777.094 (5705.813-5849.261) | 6059.05 (5955.364-6164.531) | 6354.949 (6215.862-6497.129) | 1.302673 | 19.28034 |
| Fars | 5174.29 (5150.462-5198.229) | 5321.588 (5283.304-5360.151) | 5576.54 (5511.419-5642.434) | 5843.811 (5749.11-5940.081) | 6124.006 (5997.024-6253.695) | -4.30557 | 19.04605 |
| Gilan | 5413.594 (5378.304-5449.119) | 5533.971 (5477.782-5590.754) | 5740.848 (5646.657-5836.655) | 5955.781 (5820.695-6094.041) | 6179.066 (6000.327-6363.093) | -0.28677 | 14.00202 |
| Golestan | 5606.508 (5572.956-5640.262) | 5763.74 (5709.879-5818.11) | 6035.749 (5944.259-6128.65) | 6320.722 (6187.853-6456.452) | 6619.288 (6441.365-6802.141) | 1.193803 | 18.28123 |
| Hamadan | 4904.075 (4884.816-4923.409) | 5003.691 (4973.018-5034.552) | 5174.299 (5122.827-5226.286) | 5350.813 (5276.94-5425.715) | 5533.442 (5435.672-5632.96) | -0.91001 | 13.63226 |
| Hormozgan | 5428.484 (5399.989-5457.129) | 5561.812 (5516.226-5607.776) | 5791.359 (5714.354-5869.403) | 6030.406 (5919.19-6143.717) | 6279.357 (6131.248-6431.053) | 1.422088 | 16.15656 |
| Ilam | 5378.727 (5351.68-5405.911) | 5514.871 (5471.581-5558.506) | 5749.657 (5676.479-5823.784) | 5994.659 (5888.886-6102.34) | 6250.313 (6109.331-6394.561) | 2.2008 | 16.638 |
| Isfahan | 5300.619 (5266.918-5334.535) | 5413.576 (5359.911-5467.777) | 5607.342 (5517.277-5698.867) | 5808.214 (5678.914-5940.432) | 6016.464 (5845.275-6192.618) | -7.21468 | 13.57455 |
| Kerman | 5414.551 (5380.17-5449.155) | 5566.808 (5511.564-5622.625) | 5830.203 (5736.335-5925.696) | 6106.145 (5969.838-6245.773) | 6395.24 (6212.761-6583.464) | -4.48997 | 18.46854 |
| Kermanshah | 5349.208 (5317.047-5381.564) | 5467.633 (5416.318-5519.433) | 5670.877 (5584.571-5758.517) | 5881.704 (5757.586-6008.498) | 6100.405 (5935.82-6269.553) | 1.980797 | 14.03243 |
| Khorasan-e-Razavi | 5393.87 (5357.627-5430.358) | 5567.837 (5509.495-5626.795) | 5870.539 (5770.874-5971.914) | 6189.976 (6044.354-6339.081) | 6527.112 (6330.893-6729.363) | -2.98144 | 21.27361 |
| Khuzestan | 5816.868 (5777.028-5856.981) | 5986.664 (5922.689-6051.331) | 6280.898 (6172.115-6391.598) | 6589.795 (6431.619-6751.858) | 6914.099 (6702.015-7132.888) | 4.173722 | 18.9854 |
| Kohgiluyeh and Boyer-Ahmad | 5205.577 (5182.977-5228.276) | 5357.801 (5321.54-5394.308) | 5621.5 (5559.846-5683.828) | 5898.225 (5808.542-5989.268) | 6188.623 (6068.314-6311.268) | -0.15202 | 20.11071 |
| Kurdistan | 5234.562 (5209.801-5259.44) | 5352.606 (5313.116-5392.388) | 5555.378 (5488.93-5622.622) | 5765.951 (5670.306-5863.188) | 5984.642 (5857.677-6114.316) | 0.607713 | 14.68221 |
| Lorestan | 5358.533 (5331.15-5386.055) | 5498.827 (5455.066-5542.934) | 5740.979 (5666.981-5815.915) | 5993.957 (5886.863-6102.93) | 6258.262 (6115.297-6404.437) | -0.21388 | 17.31599 |
| Markazi | 5464.488 (5434.316-5494.828) | 5600.678 (5552.423-5649.351) | 5835.375 (5753.843-5918.058) | 6080.084 (5962.268-6200.217) | 6335.249 (6178.254-6496.215) | 1.52566 | 16.24101 |
| Mazandaran | 5542.262 (5504.939-5579.838) | 5656.573 (5597.156-5716.618) | 5852.412 (5752.772-5953.773) | 6055.103 (5912.19-6201.457) | 6264.886 (6075.872-6459.758) | 0.047805 | 12.73382 |
| North Khorasan | 5561.607 (5532.742-5590.623) | 5703.929 (5657.699-5750.54) | 5949.396 (5871.182-6028.663) | 6205.589 (6092.454-6320.848) | 6472.983 (6322.089-6627.519) | 3.232083 | 16.75059 |
| Qazvin | 5121.154 (5097.486-5144.933) | 5234.21 (5196.436-5272.258) | 5428.239 (5364.666-5492.567) | 5629.515 (5538.023-5722.52) | 5838.324 (5716.913-5962.316) | 0.628199 | 14.45469 |
| Qom | 5322.135 (5296.991-5347.398) | 5463.877 (5423.544-5504.51) | 5708.867 (5640.421-5778.146) | 5965.287 (5865.96-6066.307) | 6233.738 (6100.807-6369.59) | 0.038829 | 17.9425 |
| Semnan | 5614.434 (5576.557-5652.569) | 5716.035 (5655.868-5776.842) | 5889.569 (5789.099-5991.781) | 6068.503 (5925.038-6215.437) | 6253.015 (6064.113-6447.792) | 3.708804 | 11.25173 |
| Sistan and Baluchistan | 4909.304 (4880.446-4938.333) | 5019.075 (4972.984-5065.594) | 5207.573 (5129.955-5286.373) | 5403.248 (5291.504-5517.371) | 5606.391 (5458.063-5758.79) | -4.40444 | 14.37747 |
| South Khorasan | 5221.15 (5196.36-5246.057) | 5340.265 (5300.684-5380.142) | 5545.033 (5478.355-5612.521) | 5757.771 (5661.707-5855.463) | 5978.737 (5851.107-6109.145) | -2.99579 | 15.16734 |
| Tehran | 5149.525 (5118.5-5180.738) | 5285.277 (5235.561-5335.466) | 5519.774 (5435.566-5605.288) | 5765.019 (5643.068-5889.611) | 6021.554 (5858.698-6188.947) | -6.09309 | 17.15239 |
| West Azarbayejan | 4948.377 (4928.492-4968.342) | 5064.001 (5032.279-5095.92) | 5262.789 (5209.361-5316.755) | 5469.447 (5392.453-5547.514) | 5684.292 (5581.963-5788.443) | -1.20725 | 15.46377 |
| Yazd | 5739.583 (5710.29-5769.026) | 5913.387 (5866.334-5960.816) | 6214.217 (6134.161-6295.304) | 6529.319 (6412.894-6647.816) | 6858.981 (6702.963-7018.532) | 3.825884 | 20.22722 |
| Zanjan | 5274.881 (5245.111-5304.824) | 5356.134 (5308.897-5403.814) | 5494.328 (5415.724-5574.16) | 5636.083 (5524.294-5750.32) | 5781.511 (5634.927-5932.215) | -1.90888 | 9.544048 |
Table 3.
The estimated age-standardized prevalence rates (ASPR) of ischemic heart disease (IHD) per 100,000 population in males, including 95% confidence intervals, are presented at 5-year intervals from 2022 to 2040, alongside the percentage changes in IHD prevalence for the periods 1990-2021 and 2021-2040 across Iran and its 31 provinces
| ASPR, 2022 | ASPR, 2025 | ASPR, 2030 | ASPR, 2035 | ASPR, 2040 | Percentage change (1990-2021) | Percentage change (2021-2040) | |
|---|---|---|---|---|---|---|---|
| Iran (Islamic Republic of) | 7426.43 (7383.687-7469.421) | 7585.857 (7517.673-7654.659) | 7859.353 (7744.742-7975.665) | 8142.903 (7978.185-8311.037) | 8436.891 (8218.608-8661.006) | -2.15141 | 14.73827 |
| Alborz | 7806.973 (7756.012-7858.268) | 7942.881 (7862.001-8024.59) | 8175.461 (8040.543-8312.633) | 8415.495 (8222.976-8612.497) | 8662.946 (8409.59-8923.891) | 1.907101 | 11.85004 |
| Ardebil | 7745.466 (7700.163-7791.035) | 7877.326 (7805.357-7949.96) | 8102.13 (7982.037-8224.035) | 8333.389 (8162.081-8508.304) | 8571.289 (8345.986-8802.695) | 4.187685 | 11.75213 |
| Bushehr | 7719.671 (7669.367-7770.303) | 7875.834 (7795.755-7956.732) | 8143.184 (8008.978-8279.632) | 8419.645 (8227.31-8616.461) | 8705.529 (8451.359-8967.312) | 1.113403 | 14.16074 |
| Chahar Mahaal and Bakhtiari | 7516.466 (7479.162-7553.955) | 7637.316 (7578.1-7696.995) | 7843.07 (7744.372-7943.026) | 8054.37 (7913.743-8197.5) | 8271.367 (8086.626-8460.338) | -0.19157 | 11.28079 |
| East Azarbayejan | 7454.212 (7413.042-7495.611) | 7637.21 (7571.338-7703.655) | 7952.347 (7841.068-8065.204) | 8280.626 (8119.903-8444.528) | 8622.606 (8408.562-8842.092) | -0.14868 | 17.03288 |
| Fars | 7230.214 (7185.312-7275.398) | 7381.998 (7310.32-7454.381) | 7642.112 (7521.664-7764.5) | 7911.427 (7738.471-8088.278) | 8190.271 (7961.318-8425.863) | -5.15568 | 14.52507 |
| Gilan | 7542.951 (7491.105-7595.158) | 7677.361 (7595.082-7760.542) | 7907.663 (7770.612-8047.152) | 8145.892 (7950.632-8345.952) | 8392.158 (8135.505-8656.847) | -1.80203 | 12.23844 |
| Golestan | 7899.983 (7852.322-7947.934) | 8088.898 (8012.676-8165.846) | 8413.957 (8285.32-8544.597) | 8752.222 (8566.623-8941.858) | 9104.239 (8857.333-9358.058) | 1.167663 | 16.60212 |
| Hamadan | 6895.304 (6855.167-6935.677) | 7003.05 (6939.388-7067.297) | 7186.421 (7080.443-7293.987) | 7374.646 (7223.819-7528.627) | 7567.857 (7369.939-7771.101) | -1.10138 | 11.2499 |
| Hormozgan | 7590.366 (7546.018-7634.975) | 7766.165 (7695.287-7837.697) | 8066.95 (7947.483-8188.213) | 8378.239 (8206.133-8553.957) | 8700.818 (8472.248-8935.556) | 1.117082 | 16.03031 |
| Ilam | 7523.521 (7477.73-7569.592) | 7688.215 (7615.012-7762.13) | 7970.882 (7847.696-8096.034) | 8264.097 (8087.015-8445.131) | 8568.25 (8333.591-8809.647) | 1.838081 | 15.36585 |
| Isfahan | 7413 (7360.08-7466.301) | 7541.682 (7457.699-7626.607) | 7761.354 (7621.316-7903.955) | 7987.695 (7787.999-8192.488) | 8220.901 (7958.299-8492.123) | -7.02068 | 11.5312 |
| Kerman | 7551.281 (7492.774-7610.248) | 7746.296 (7652.493-7841.263) | 8082.562 (7923.842-8244.528) | 8433.414 (8203.942-8669.458) | 8799.488 (8493.651-9116.614) | -5.55926 | 17.61926 |
| Kermanshah | 7495.529 (7441.043-7550.414) | 7639.758 (7553.025-7727.488) | 7886.27 (7741.103-8034.164) | 8140.674 (7933.001-8353.795) | 8403.243 (8129.335-8686.399) | 0.227663 | 13.06709 |
| Khorasan-e-Razavi | 7506.135 (7460.406-7552.144) | 7702.897 (7629.667-7776.831) | 8043.456 (7919.562-8169.287) | 8400.339 (8221.08-8583.498) | 8774.22 (8535.002-9020.118) | -3.68153 | 18.0374 |
| Khuzestan | 8129.691 (8080.091-8179.596) | 8307.552 (8228.379-8387.487) | 8612.836 (8479.7-8748.066) | 8929.51 (8738.133-9125.083) | 9257.965 (9004.324-9518.759) | 3.269808 | 15.08424 |
| Kohgiluyeh and Boyer-Ahmad | 7283.036 (7239.526-7326.808) | 7473.836 (7404.108-7544.222) | 7803.063 (7684.979-7922.967) | 8146.866 (7975.907-8321.503) | 8505.892 (8277.684-8740.418) | 0.10546 | 19.29039 |
| Kurdistan | 7295.281 (7258.814-7331.931) | 7452.555 (7394.461-7511.101) | 7722.452 (7624.868-7821.261) | 8002.407 (7862.18-8145.078) | 8292.834 (8106.99-8482.827) | -0.04367 | 15.01564 |
| Lorestan | 7586.293 (7543.38-7629.45) | 7735.769 (7667.412-7804.737) | 7991.515 (7876.917-8107.787) | 8255.776 (8091.537-8423.372) | 8528.843 (8311.811-8751.588) | 0.869362 | 14.03905 |
| Markazi | 7601.83 (7556.578-7647.354) | 7783.135 (7710.782-7856.167) | 8095.18 (7973.102-8219.125) | 8420.019 (8243.917-8599.882) | 8758.203 (8523.966-8998.875) | 1.15081 | 16.46043 |
| Mazandaran | 7721.806 (7674.027-7769.882) | 7845.291 (7769.486-7921.836) | 8054.807 (7928.565-8183.06) | 8269.24 (8089.527-8452.948) | 8488.883 (8253.021-8731.488) | -0.09436 | 10.67728 |
| North Khorasan | 7736.689 (7690.338-7783.319) | 7916.115 (7842.076-7990.854) | 8224.634 (8099.884-8351.307) | 8545.415 (8365.691-8729.002) | 8878.961 (8640.21-9124.31) | 3.011093 | 16.04013 |
| Qazvin | 7166.775 (7125.145-7208.648) | 7292.024 (7225.839-7358.817) | 7505.687 (7395.142-7617.89) | 7725.651 (7567.838-7886.771) | 7952.106 (7744.394-8165.417) | 1.668808 | 12.25773 |
| Qom | 7404.619 (7367.478-7441.947) | 7579.399 (7519.862-7639.413) | 7885.137 (7783.986-7987.655) | 8213.961 (8066.225-8364.618) | 8575.147 (8374.394-8781.405) | -0.05907 | 17.70441 |
| Semnan | 7780.69 (7729.347-7832.373) | 7898.844 (7817.505-7981.028) | 8099.777 (7964.592-8237.251) | 8305.832 (8113.729-8502.47) | 8517.139 (8265.431-8776.487) | 3.86397 | 10.37179 |
| Sistan and Baluchistan | 6906.901 (6866.883-6947.153) | 7049.658 (6985.886-7114.011) | 7294.336 (7187.307-7402.958) | 7547.73 (7394.14-7704.508) | 7810.169 (7606.934-8018.83) | -4.35092 | 14.29495 |
| South Khorasan | 7320.839 (7285.796-7356.05) | 7490.288 (7434.298-7546.7) | 7781.821 (7687.427-7877.373) | 8084.972 (7948.885-8223.384) | 8400.089 (8219.171-8584.98) | -1.87544 | 16.49119 |
| Tehran | 7163.211 (7125.316-7201.308) | 7340.206 (7279.581-7401.334) | 7645.093 (7542.67-7748.902) | 7962.812 (7814.851-8113.564) | 8293.915 (8096.82-8495.788) | -6.03696 | 16.90092 |
| West Azarbayejan | 6933.353 (6894.618-6972.306) | 7062.954 (7001.389-7125.059) | 7284.439 (7181.493-7388.853) | 7512.973 (7365.749-7663.119) | 7748.787 (7554.632-7947.891) | -2.4086 | 13.00491 |
| Yazd | 7954.766 (7906.399-8003.427) | 8183.733 (8106.108-8262.098) | 8579.355 (8447.545-8713.208) | 8992.915 (8801.614-9188.331) | 9424.822 (9168.947-9687.733) | 3.652666 | 20.17193 |
| Zanjan | 7326.618 (7281.001-7372.52) | 7425.109 (7352.924-7498.009) | 7592.14 (7472.444-7713.777) | 7762.847 (7593.167-7936.368) | 7937.322 (7715.538-8165.558) | -1.58106 | 9.499161 |
Future perspective: 2021 to 2040
Both
Looking ahead to 2040, Iran faces a significant escalation in its IHD burden, with the national ASPR projected to rise by 16% to reach 7,336.1 per 100,000 (Figure 2). However, this increase will not be evenly distributed. The geographic disparities observed in recent years are expected to persist, with central and northern provinces like Yazd, Khuzestan, and North Khorasan continuing to shoulder the highest absolute burdens. Meanwhile, provinces in the west and southeast, such as Hamadan and Sistan and Baluchistan, are likely to maintain lower prevalence rates. More concerning is the uneven speed of this rise. Provinces like Yazd and Khorasan-e-Razavi are projected to see their ASPR surge by over 20%, indicating a rapid and worsening epidemiological transition in these specific regions. In contrast, areas like Zanjan and Alborz are expected to experience much slower growth, suggesting more stable disease dynamics (Table 1; Figures 3, 4 and 5). This divergence highlights that a uniform national strategy will likely fail; instead, public health resources must be strategically allocated to target the high-risk provinces where the burden is growing most rapidly.
Female
Similarly, the national ASPR for women is expected to climb by 16.36%, reaching 6,184.2 per 100,000 by 2040. This rise will be marked by pronounced geographic inequalities. Central and northern provinces, particularly Khuzestan, Yazd, and Golestan, are projected to shoulder the heaviest burdens, with rates exceeding 6,600 per 100,000. In contrast, western and southeastern regions such as Hamadan, Sistan and Baluchistan, and West Azarbayejan are likely to maintain lower prevalence, staying below 5,700 per 100,000. Crucially, the speed of this increase varies significantly: Khorasan-e-Razavi, Yazd, and Kohgiluyeh and Boyer-Ahmad are anticipated to witness the sharpest spikes in female ASPR, reflecting a rapid deterioration in cardiovascular health markers in these areas. Conversely, provinces like Zanjan, Semnan, and Chahar Mahaal and Bakhtiari are expected to show more modest growth, indicating relatively stable risk profiles for women there (Table 2; Figures 3, 4 and 5). This divergence underscores the necessity of moving away from generic national health policies toward gender-sensitive and region-specific interventions. Prioritizing preventive care and lifestyle modifications in high-growth provinces like Yazd and Khorasan-e-Razavi is essential to mitigate the escalating burden of IHD among Iranian women in the coming decades.
Male
By 2040, the national ASPR for males is projected to increase by 14.73%, reaching 8,436.8 per 100,000 (95% CI: 8,218.6-8,661.0). As with the total population and females, this burden will be unevenly distributed geographically. Yazd, Khuzestan, and Golestan are anticipated to face the highest male IHD rates, while Hamadan, West Azarbayejan, and Sistan and Baluchistan are expected to maintain the lowest. However, the pace of this increase varies significantly across regions. Yazd is projected to experience the most dramatic rise in male ASPR at 20.17%, indicating a rapid worsening of cardiovascular risk factors in this province. In contrast, Zanjan is expected to see the smallest increase (9.50%), suggesting more effective risk management or stable demographics among men in that area (Table 3; Figures 3, 4 and 5). This suggests that current preventive strategies may be insufficient in high-growth regions, necessitating targeted male-specific health interventions in provinces like Yazd to curb the escalating prevalence of IHD.
Age groups
To better understand the shifting epidemiology of IHD, we analyzed trends across two key age groups: those under 45 years and those over 45. The data reveals a concerning acceleration in disease burden among younger populations. For individuals under 45, the ASPR rose by 13.20% from 1990 (698.75 per 100,000) to 2021 (790.98 per 100,000) and is projected to surge by a further 23.01% by 2040, reaching 972.97 per 100,000 (Table S1). This rapid escalation suggests a worsening of early-onset risk factors. In contrast, the over-45 group, which bears the absolute highest burden (14,133.06 per 100,000 in 2021), has seen a more modest historical increase of 5.48% from 1990 to 2021. However, this group is also projected to see a significant rise of 16.44% by 2040, reaching 16,457.45 per 100,000 (Table S2). While the older population remains the most affected overall, the rate of change is disproportionately higher in the younger demographic, signaling a critical need for preventive strategies targeting early adulthood (Tables S1, S2). This highlights an urgent need for targeted interventions focused on lifestyle modifications and early screening for young Iranians to prevent a future surge in early-onset cardiovascular disease.
Discussion
Our study opens an important perspective into the future trends of IHD in Iran and serves as critical information for health policy makers by describing the current and future epidemiological picture of the disease. In fact, this information can provide a guide for health stakeholders and other decision-makers to make the right decisions to achieve Sustainable Development Goal 3.4 (SDG 3.4) in the country. Our findings showed an upward trend in cardiovascular disease across the country and in all provinces by 2040, affecting both men and women. This trend can imply a need for urgent action to effectively address this growing problem.
The historical trend of IHD in Iran show a decrease in ASPRs from 1990 to 2009, followed by an increase until 2021, with a continuing upward trend expected through 2040. We will first examine historical trends and then discuss future projections to elucidate the epidemiology of IHD in Iran. Considering historical trends, one study [5] noted an insignificant change in the ASPR of IHD from 1990 to 2019, which aligns with the observed decreasing and subsequent increasing trends of IHD. However, this national pattern may reflect moderate progress in mitigating IHD risk factors from 1990 to 2009 and in improving healthcare access, although the likelihood remains low and may be influenced by unobservable factors. Moreover, this may be related to the implementation of a specific program that was later suspended or scaled back for various reasons. In another scenario this biphasic trend is likely linked to population aging, increasing metabolic risk factors, urbanization-driven lifestyle changes, longer patient survival, and enhanced disease detection through improved registration systems.
We observed a significant increase in the national prevalence of IHD, reaching 7336.1 per 100,000 population by 2040. This finding is supported by the Shi et al. [15] study, which showed a global increase in the prevalence and incidence of coronary heart disease by 2050, as IHD is a common type of CVSs. This trend may be due to individual aging, urbanization, and lifestyle changes such as increased consumption of unhealthy foods (fast foods), low physical inactivity, and more exposure to stress. Farzadfar et al. [16] predicted that by 2030, physical inactivity would increase to 36.2% in Iranian men and 26.7% in women, along with an increase in other risk factors such as obesity, diabetes, and hypertension.
Additionally, we observed a significant change in the ASPR between 1990-2021 and 2021-2040 across provinces. These differences in IHD prevalence trends can be linked to regional (provincial) disparities in socioeconomic development, healthcare infrastructure, and the prevalence of modifiable and non-modifiable risk factors, such as diabetes, obesity, lifestyle, tobacco use and hypertension [17-19]. Provinces with higher ASPRs, such as Khuzestan and Yazd, may face greater exposure to these risk factors owing to unhealthy diets, physical inactivity, and limited access to preventive services. Thus, evidence [20] shows that Yazd province has the highest prevalence of insufficient physical activity in Iran at 63.45%, followed by Khuzestan at 53.38%, which is higher than in most other provinces [21]. This underscores the need for interventions to modify lifestyle and/or control modifiable risk factors. Moreover, the highest ASPR in provinces such as Yazd, Khuzestan, and North Khorasan by 2040 can be attributed to a higher rate of hypertension and consumption of much higher amounts of salt by 2030 [16]. In contrast to the decreasing predicted trend in Iran, Yazd and North Khorasan experienced an increasing trend in salt intake. North Khorasan has also been predicted to have higher rates of obesity and diabetes than the overall rate in Iran [16].
This once again emphasizes the need for interventions to change lifestyle and manage modifiable risk factors, as a significant portion of the burden of these diseases is rooted in modifiable risk factors. In contrast, provinces such as Hamedan, West Azerbaijan, and Sistan and Baluchestan had the lowest ASPR rates in 2021 and are expected to maintain this status until 2040, likely due to effective public health measures and education, improved healthcare delivery, and better risk factor management [22], which is likely more related to the ethnic and cultural makeup of the people of these provinces through adherence to a healthy and traditional lifestyle.
Furthermore, we observed higher ASPR for men than women at the national and provincial levels, which is consistent with global evidence in this regard [23]. This discrepancy has been attributed in part to the regulatory role of estrogen in cardiovascular disease [24,25]. Furthermore, some evidence suggests that heavy social responsibilities and higher psychological stress in men may be triggers for men to not adhere to a healthy lifestyle, ultimately leading to excessive alcohol consumption, late night waking, smoking, high-fat diets, sedentary behavior, etc. [26-28].
Our study is the first in Iran to provide a comprehensive roadmap for IHD by 2040 using GBD data and a robust IDM model that considers the interrelationships of epidemiological indicators, including prevalence, incidence, and mortality. As a result, the findings of this study can provide valuable information for policymakers and public health professionals for future planning and resource allocation. By knowing the differences between provinces, while allocating resources, healthy lifestyle patterns or contributing factors in areas with lower prevalence rates can be used. In addition, we attempted to provide sex- and age-specific data to better understand the epidemiology of IHD in Iran. Similar to other studies, we faced some limitations: Reliance on GBD data may lead to bias due to incomplete or poor-quality health records in certain provinces, potentially affecting accuracy. However, these effects appear to be minimal due to generally consistent registration systems across provinces.
Conclusion
Our study shows the increasing burden of IHD in Iran and its provinces. Our results revealed significant provincial and gender disparities in the prevalence trend, and further studies are needed to more precisely explain the origins of these inter-provincial differences by focusing on modifiable risk factors and lifestyle. It is hoped that these studies can provide a glimmer of hope for better prevention, treatment, and management of this disease in the country. On the other hand, the projected increase in IHD cases by 2040 indicates the urgent need for comprehensive public health strategies and targeted policies to control the burden of this disease, especially in high-burden and deprived provinces. This can further highlight the importance of focusing on modifiable risk factors.
Acknowledgements
This work was supported by the Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences (grant # 14021682).
Disclosure of conflict of interest
None.
Ethic considerations
This project was approved by the Ethics Committee of Qom University of Medical Sciences, Qom, Iran (Approval No: IR.MUQ.REC.1403.196).
Supporting Information
References
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