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. Author manuscript; available in PMC: 2014 Oct 2.
Published in final edited form as: Circulation. 2014 Feb 26;129(14):1483–1492. doi: 10.1161/CIRCULATIONAHA.113.004042

Temporal Trends in Ischemic Heart Disease Mortality in 21 World Regions, 1980 to 2010 The Global Burden of Disease 2010 Study

Andrew E Moran 1, Mohammad H Forouzanfar 1, Gregory A Roth 1, George A Mensah 1, Majid Ezzati 1, Christopher JL Murray 1, Mohsen Naghavi 1
PMCID: PMC4181359  NIHMSID: NIHMS625986  PMID: 24573352

Abstract

Background

Ischemic heart disease (IHD) is the leading cause of death worldwide. The Global Burden of Diseases, Risk Factors and Injuries 2010 Study estimated global and regional IHD mortality from 1980 to 2010.

Methods and Results

Sources for IHD mortality estimates were country-level surveillance, verbal autopsy, and vital registration data. Regional income, metabolic and nutritional risk factors, and other covariates were estimated from surveys and a systematic review. An estimation and validation process led to an ensemble model of IHD mortality for 21 world regions. Globally, age-standardized IHD mortality has declined since the 1980s, and high-income regions (especially Australasia, Western Europe, and North America) experienced the most remarkable declines. Age-standardized IHD mortality increased in former Soviet Union countries and South Asia in the 1990s and attenuated after 2000. In 2010, Eastern Europe and Central Asia had the highest age-standardized IHD mortality rates. More IHD deaths occurred in South Asia in 2010 than in any other region. On average, IHD deaths in South Asia, North Africa and the Middle East, and sub-Saharan Africa occurred at younger ages in comparison with most other regions.

Conclusions

In most world regions, particularly in high-income regions, age-standardized IHD mortality rates have declined significantly since 1980. High age-standardized IHD mortality in Eastern Europe, Central Asia, and South Asia point to the need to prevent and control established risk factors in those regions and to research the unique behavioral and environmental determinants of higher IHD mortality.

Keywords: epidemiology, mortality, myocardial ischemia, trends, world health

Ischemic heart disease (IHD) was the leading cause of death worldwide in 2010.1 Age-standardized IHD mortality has declined in high-income nations since 1980, in large part, because of a combination of improved primary prevention (improvements in risk factors) and improved secondary prevention (improved treatment of acute and chronic IHD).2–5 On average, IHD deaths have been pushed to older ages in the high-income regions. However, in the past, the IHD epidemic has evolved variably in different regions and nations.6 In some low- and middle-income regions, accelerated lifestyle changes, economic stresses, and other factors may be leading to increased IHD incidence often occurring in middle-aged adults, and changing the late 20th century paradigm of IHD as a disease of the affluent and the elderly.7

Measuring total IHD deaths and age-standardized IHD mortality rates is essential for assessing the burden of IHD and planning prevention programs. Global and regional analysis of IHD mortality trends is complicated by numerous factors, including changes in International Classification of Diseases (ICD) categories over time, sparse or low-quality original vital registration data in some regions, and variations in the degree of incorrect coding of IHD deaths. As part of the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2010 Study, we used novel estimation methods to assess the numbers of IHD deaths, IHD mortality rates, and years of life lost (YLL) attributable to IHD for 21 world regions over the years 1980 to 2010, and provide uncertainty ranges for these estimates.

Methods

Definition of IHD Death

Detailed IHD mortality definitions and estimation methods are available elsewhere.8,9 In brief, IHD deaths fall into 2 categories: acute myocardial infarction deaths and sudden cardiac deaths. IHD has been consistently defined as an underlying cause of death across ICD revisions (most recently ICD-10 I20–I25 and ICD-9 410–414).8 A proportion of IHD deaths are erroneously assigned on death certificates to either nonfatal ICD conditions (eg, senility) or conditions not defined as an underlying cause of death (eg, heart failure, hypertension, or cardiac conduction disorders). The GBD developed methods for systematically reallocating these undefined or erroneously assigned deaths to IHD based on the total distribution of actual causes of death by the country, sex, age, and year.8,10

IHD Mortality Source Data

Cause-specific mortality data were gathered from vital registration, verbal autopsy, surveillance systems, surveys/censuses, or police report and aggregated in a central database. Data sources and availability varied substantially among GBD 2010 regions (Tables I and II in the online-only Data Supplement). Causes of death were mapped across revisions and national variations of the ICD over time, incomplete data were adjusted for reporting bias, erroneously coded deaths were redistributed, deaths were distributed to GBD age categories, and trends were smoothed to eliminate year-to-year fluctuations.1 No gold standard for validating GBD classification and redistribution algorithms exists (such as large-scale autopsy studies), so countries with the most complete vital registration and adherence to recommended cause-of-death coding practices were used as the standard. Even in the best of settings, there are problems with erroneous coding of deaths to inappropriate ICD codes, and GBD methods have been demonstrated to improve cause-of-death estimation.11 Overall, numbers of IHD deaths increased 21.5% after redistribution of undefined- coded deaths to IHD (Table III in the online-only Data Supplement). Globally, 76.9% of deaths incorrectly coded as heart failure, 47.2% incorrectly coded as hypertension, and 89.9% incorrectly coded as all cardiac conduction disorders were redistributed to IHD.9

IHD Mortality Models

Multilevel IHD mortality regression models were used to improve estimation for regions with sparse or outlying mortality data (Online- only Data Supplement Material). Models include fixed effects from covariates and nested random effects on super region, region, country, and age. Separate models were developed for males and females. Potential model covariates and their directions of effect were selected based on a comprehensive review by the comparative risk assessment arm of the GBD 2010 study, and included standard IHD risk factors (country mean blood pressure and cholesterol), behavioral variables (physical activity, diet, alcohol consumption), and contextual variables (per capita income, mean education level, and health system access).9 Independent ecological associations of covariates with IHD mortality were first tested in mixed-effects regressions, adding covariates stepwise, added in order from higher to lower evidence of causal association with IHD in past studies.9 Seventeen covariates produced multivariate coefficients with a plausible direction and were significant at the <0.05 level and were retained for subsequent models. With the use of IHD mortality data and the covariates selected, the Cause of Death Ensemble Model ranked outof-sample performance of individual IHD mortality statistical models and, with the use of a weighting algorithm, combined the best individual models into ensemble models.12 Out-of-sample predictive validity of the ensemble and individual predictive models were evaluated by ranking each model's root mean squared error of the natural log of the death rate (the average difference—or error—between model estimates and test set data for each year), the fraction of the time the trend in the prediction matched the temporal trend in the data (trend test), and the proportion of the test data set included in the 95% prediction interval of the model (coverage). All-cardiovascular death and total mortality envelopes were estimated independently and used to scale IHD mortality so that the sum of different cardiovascular disease–caused deaths would be equal to the all-cardiovascular disease death envelope, and all-cause deaths would be equal to the total mortality envelope.

Mean body mass index, systolic blood pressure (mm Hg), total cholesterol (mmol/L), and level of tobacco smoking (active smoking prevalence and mean cigarettes per day) were all significant predictors of IHD mortality and contributed most frequently to individual IHD models developed for both men and women.9 Alcohol (liters per capita) was the only covariate entered into models without specifying the direction of association (ie, not specifying benefit or harm) and contributed to 11% of male models and 42% of female models. Contextual covariates such as lower educational status (years per capita), lower income (US dollars per capita), high elevation (percentage of population dwelling at >1500 m), and high war deaths (rate per 1000 person-years) all contributed more to female than to male ensemble models.9 The prevalence of diabetes mellitus contributed to 30% of male ensemble models, but to zero female models. The root mean squared error of the best male IHD mortality model was 0.58, predicted the correct trend 62% of the time in test data, and included 90% of test data within the 95% confidence intervals around annual estimates. The best female model had a root mean squared error of 0.65, predicted the correct trend 61% of the time in test data sets, and included 91% of the test data within the 95% confidence interval.9

YLL were calculated by multiplying observed IHD deaths for a specific age in the year of interest by the age-specific reference life expectancy estimated by the use of life table methods (eg, 86.0 years at birth).13 Numbers of IHD deaths and YLL attributable to IHD death are reported for all 21 GBD regions for the years 1980 to 2010 (regions listed in Table IV in the online-only Data Supplement). Crude IHD mortality rates were calculated by dividing annual IHD deaths by the total population (all ages) at risk in that year. These rates were also age standardized by the direct method by using the 5-year GBD age categories and the World Health Organization standard population.14 To assist with interpretation, IHD mortality rate trend plots used 7 super regions: Latin America/Caribbean, East Asia/ Pacific, South Asia, North Africa/Middle East, sub-Saharan Africa, Eastern Europe/Central Asia, and High Income (Table IV in the online-only Data Supplement).

Results

There were >7.0 million IHD deaths worldwide in 2010, in comparison with 4.5 million IHD deaths in 1980, 5.2 million in 1990, and 6.3 million in 2000 (Table V in the online-only Data Supplement). In 2010, the highest age-standardized IHD death rates were concentrated in a cluster of regions extending from Eastern Europe and Central Asia to Central Europe, North Africa/Middle East, and South Asia (Figure 1). High age-standardized IHD death rates were also found in the Caribbean region. Of all global IHD deaths in the year 2010, 25.6% occurred in persons <65 years of age (95% confidence interval, 25.9%–27.8%), in comparison with 26.5% in 1980 (95% confidence interval, 23.9%–26.6%).

Figure 1.

Figure 1

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Map of age-standardized ischemic heart disease mortality rate per 100 000 persons in 21 world regions, 2010, the Global Burden of Disease 2010 Study.

The number of IHD deaths increased most since 1980 in the ≥80-years age group, the same group in which about half of all female IHD deaths occurred in 2010 (Figure 2). Rarely, IHD deaths were recorded in infants and children, perhaps because of incorrect cause-of-death reporting. Crude IHD mortality rates in the High Income super regions were among the highest in the world in 1980, but declined substantially by 2005 (Figure I in the online-only Data Supplement). By far the highest crude rates of IHD deaths and the steepest increase since 1980 were observed in the regions of the former Soviet Union (Eastern Europe/Central Asia), especially among males. The South Asia and East Asia/Pacific super regions also saw steady crude IHD death rate increases after 1980.

Figure 2.

Figure 2

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Total IHD deaths by age group, all world regions (A, males; B, females), 1980 to 2010, the Global Burden of Disease 2010 Study. IHD indicates ischemic heart disease.

When mortality rates were age standardized, in comparison with the crude rates, IHD death rates emerged as distinctly higher in North Africa/Middle East and South Asia, 2 regions with younger populations (average age <65 years; Tables 1 and 2, Figure 3). South Asia's age-standardized death rates increased from ≈1985 to 2000; more recently rates there appear to have leveled off. Age-standardized IHD mortality remained low in sub-Saharan Africa from 1980 to 2010. The largest proportional increase in age-standardized IHD mortality between 1990 and 2010 occurred in East Asian males (38% increase), although the absolute rate remained comparatively low. On average, IHD deaths occurred at the youngest ages in North Africa/Middle East, South Asia, and sub-Saharan Africa (Figure 4).

Table 1.

Age-Standardized IHD Mortality per 100 000 persons, by Region, Males, 1990, 2005, 2010, the Global Burden of Disease 2010 Study

GBD 2010 Super Region
 Males
1990
 2005
 2010
GBD 2010 Region Mean Lower Upper Mean Lower Upper Mean Lower Upper
High income
    Asia Pacific, high income 69 60 73 49 45 56 46 42 52
    Europe, Western 183 169 192 106 103 122 93 89 108
    Australasia 209 190 216 99 94 116 91 83 108
    North America, high income 226 209 238 135 129 155 120 112 139
    Latin America, Southern 164 154 180 119 113 138 108 102 125
Eastern Europe/Central Asia
    Europe, Central 285 263 302 226 215 246 201 192 222
    Europe, Eastern 393 380 430 545 497 566 434 396 454
    Asia, Central 395 382 427 441 411 459 400 366 430
Latin America/Caribbean
    Latin America, Tropical 159 142 170 119 113 139 113 106 132
    Latin America, Central 130 121 144 115 101 120 117 103 124
    Latin America, Andean 92 85 102 73 66 80 70 63 78
    Caribbean 177 163 189 149 144 168 144 137 162
East Asia/Pacific
    Asia, Southeast 110 102 124 108 102 132 111 104 133
    Asia, East 61 53 86 83 67 91 84 65 92
    Oceania 122 106 185 117 101 179 115 98 168
North Africa / Middle East
    North Africa / Middle East 228 217 263 197 183 214 189 171 204
South Asia
    Asia, South 143 133 165 166 137 178 162 133 186
Sub-Saharan Africa
    Sub-Saharan Africa, Southern 122 93 134 76 69 96 77 68 96
    Sub-Saharan Africa, East 79 65 87 61 55 76 60 54 77
    Sub-Saharan Africa, Central 112 84 134 103 84 124 112 91 135
    Sub-Saharan Africa, West 52 47 69 60 54 73 63 56 77
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GBD indicates Global Burden of Diseases, Injuries, and Risk Factors; and IHD, ishemic heart disease.

Table 2.

Age-Standardized IHD Mortality per 100 000 Persons, by Region, Females, 1990, 2005, 2010, the Global Burden of Disease 2010 Study

GBD 2010 Super Region
 Females
1990
 2005
 2010
GBD 2010 Region Mean Lower Upper Mean Lower Upper Mean Lower Upper
High income
    Asia Pacific, high income 44 38 46 28 26 33 27 24 31
    Europe, Western 96 85 99 58 56 71 51 49 65
    Australasia 113 99 118 58 53 75 55 49 69
    North America, high income 126 111 131 83 77 107 76 68 100
    Latin America, Southern 84 78 90 62 59 76 58 54 70
Eastern Europe/Central Asia
    Europe, Central 161 154 169 131 123 139 117 110 125
    Europe, Eastern 224 216 246 272 245 284 235 209 245
    Asia, Central 243 238 262 254 241 265 225 213 242
Latin America/Caribbean
    Latin America, Tropical 105 95 111 78 73 91 73 68 88
    Latin America, Central 86 79 94 77 69 82 74 68 82
    Latin America, Andean 72 63 80 60 54 69 55 49 64
    Caribbean 133 122 139 116 111 133 112 105 150
East Asia/Pacific
    Asia, Southeast 76 69 84 70 65 90 68 63 86
    Asia, East 52 46 79 60 45 65 57 40 65
    Oceania 79 57 137 86 63 140 87 63 137
North Africa / Middle East
    North Africa / Middle East 155 148 173 134 123 143 123 114 131
South Asia
    Asia, South 109 98 131 112 89 124 106 86 120
Sub-Saharan Africa
    Sub-Saharan Africa, Southern 74 55 83 57 49 76 52 43 72
    Sub-Saharan Africa, East 59 45 65 49 42 55 47 41 55
    Sub-Saharan Africa, Central 86 67 104 80 65 96 83 68 100
    Sub-Saharan Africa, West 62 53 79 59 49 75 59 49 77
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GBD indicates Global Burden of Diseases, Injuries, and Risk Factors; and IHD, ishemic heart disease.

Figure 3.

Figure 3

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Age-standardized ischemic heart disease mortality rate per 100 000 persons by super region and globally (A, males; B, females), 1980 to 2010, the Global Burden of Disease 2010 Study.

Figure 4.

Figure 4

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Average age at the time of IHD death by super region and globally (A, males; B, females), 1980 to 2010, the Global Burden of Disease 2010 Study. IHD indicates ischemic heart disease.

Eastern Europe/Central Asia experienced steep increases in the age-standardized IHD death rate after 1990 (around the time of the breakup of the Soviet Union); age-standardized rates there declined starting in the mid-2000s (Figure 3).

Among the high-income regions, age-standardized IHD mortality rates decreased most in Australasia (≈51% decrease from 1990 to 2010), Western Europe (46% decrease), and North America (43% decrease; Tables 1 and 2). The lowest age-standardized IHD mortality rates over the period 1980 to 2010 were observed in the sub-Saharan Africa, Andean Latin America, and Asia/Pacific regions.

Regional totals of YLL attributable to IHD were highest in regions with larger populations, high IHD mortality rates, and younger average age at IHD death. The highest YLL in all years was observed in South Asia (a 72% increase since 1990), followed by Eastern Europe (Table 3, Table VI in the online-only Data Supplement). Despite having among the lowest IHD death rates in the world, East Asia ranked third in IHD YLL in 2010 and has experienced the largest proportional increase in YLL since 1990 (78% higher) because of its large and aging population. Driven both by lower IHD death rates and older average age at IHD death, the most remarkable decreases in YLL from 1990 to 2010 occurred in the high-income regions of Australasia (34% decrease) and Western Europe (32% decrease).

Table 3.

Years of Life Lost Owing to IHD, Males And Females, by Region, 1990, 2005, and 2010, the Global Burden of Disease 2010 Study

GBD 2010 Super Region
 1990
 2005
 2010
GBD 2010 Region Mean Lower Upper Mean Lower Upper Mean Lower Upper
High income
    Asia Pacific, high income 1 798146 1 620 244 1 900 184 1 812 636 1 692 038 2 018 899 1 920 451 1 752 565 2 116 832
    Europe, Western 12860688 11929 341 13 404 064 8 807 634 8 566 677 9 942 095 8 428 017 8 135 515 9 554 209
    Australasia 615 515 569 455 632 471 405 899 388 773 462 917 419 557 392 876 482 962
    North America, high income 9 769 603 9 109 634 10 256 781 8 060 007 7 735 522 9 068 844 7 825 615 7 351 893 8 948 068
    Latin America, Southern 952 977 904 836 1 037 283 933 315 898 505 1 032 393 945 652 905 779 1 055 796
Eastern Europe/Central Asia
    Europe, Central 5 597 369 5 242 998 5 831 784 5 089 778 4 920 576 5 468 643 4 835 548 4 650 986 5 210 929
    Europe, Eastern 13 363 422 13 020 191 14 332 364 21 395 103 19 746 998 22 075 817 17 671 525 16 219 642 18 315 709
    Asia, Central 2 434 441 2 366 917 2 603 885 3 358 046 3 149 985 3 497 223 3 344 003 3 095 362 3 565 863
Latin America/Caribbean
    Latin America, Tropical 2 341 808 2 193 945 2 534 789 2 779 536 2 657 763 3 083 571 3 015 732 2 872 578 3 380 191
    Latin America, Central 1 762 410 1 637 594 1 905 648 2 366 529 2 129 444 2 484 887 2 827 557 2 550 462 3 012 726
    Latin America, Andean 312 129 293 583 351 584 426 970 358 663 456 209 437 785 377 164 474 416
    Caribbean 694 309 647 297 739 747 759 499 733 454 832 392 839 991 797 218 1 046 637
East Asia/Pacific
    Asia, Southeast 4 818 933 4 360 138 5 246 287 6 704 804 6 383 138 7 672 710 7 765 379 7 361 080 8 864 297
    Asia, East 9 449 260 8 689 819 12 168 368 15 493 412 13 436 409 16 405 168 16 795 598 13 989 156 17 913 060
    Oceania 71 723 61 923 98 564 107 351 90 631 150 617 122 337 102 152 165 558
North Africa / Middle East
    North Africa / Middle East 6 521 855 6 049 947 7 091 033 7 995 777 7 402 525 8 517 971 8 822 768 7 968 594 9 343 464
South Asia
    Asia, South 17 300 420 16 157 871 19 323 777 27 628 587 23 082 187 29 334 998 29 759 902 24 854 218 33 295 998
Sub-Saharan Africa
    Sub-Saharan Africa, Southern 439 982 351 244 477 998 531 476 491 026 653 461 514 823 468 185 632 563
    Sub-Saharan Africa, East 1 414 599 1 148 746 1 545 838 1 628 544 1 446 234 1 803 904 1 781 311 1 600 930 2 000 006
    Sub-Saharan Africa, Central 508 418 404 775 597 259 666 283 576 079 770 551 805 163 697 096 940 718
    Sub-Saharan Africa, West 1 492 723 1 274 743 1 714 206 1 890 019 1 683 958 2 126 861 2 146 457 1 913 551 2 462 752
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GBD indicates Global Burden of Diseases, Injuries, and Risk Factors; and IHD, ishemic heart disease.

Discussion

In the overall GBD study, IHD was the leading cause of death worldwide in 2010.1 Our analysis of IHD mortality trends found that global age-standardized IHD mortality has declined since 1980. At the regional level, another, more complex story emerged: the age-standardized IHD death rate has declined steeply since 1980 in the Western, high-income regions, but has increased in Eastern Europe, Central Asia, South Asia, and East Asia. Reflecting its large population and relatively young average age at IHD death, the South Asia region had the highest number of life-years lost to premature IHD deaths.

An IHD epidemic emerged in Eastern Europe and Central Asia after the breakup of the Soviet Union in the early 1990s: this group of regions has had by far the highest crude and age- standardized IHD death rates of any region. Eastern Europe and Central Asia regions experienced a combined 21 million YLL in 2010 because of IHD, second only to South Asia, despite having less than a fifth of South Asia's population. The reasons for high IHD death rates in the Eastern Europe region are under debate: peak IHD death-rate years have coincided with economic downturns, and the greatest fluctuations have occurred in the nonmyocardial infarction (ie, cardiac arrest, atherosclerotic heart disease, and other IHD) portion of IHD deaths.15 There is strong evidence that heavy alcohol exposure is the cause of many deaths ascribed to IHD in this region, although the causal pathway needs to be better defined.15,16

Perhaps most concerning are high age-standardized IHD death rates in regions like North Africa/Middle East and South Asia where deaths occurred at younger ages on average, meaning IHD deaths were more likely to occur in productive, working-age adults. This represents the greatest loss for families and national economies.7,17 In the overall GBD 2010 study, regions such as South, Central, and East Asia; Central, Andean, and Tropical Latin America; and North Africa/Middle East stood out for having a double burden of YLL owing to cardiovascular and infectious diseases.

Dietary patterns have shifted worldwide in both high-and low-income regions to more consumption of edible oils, animal fats, and sugar-sweetened beverages.18 Earlier adoption of unhealthy lifestyles and higher risk factor exposures at younger ages may, in part, explain the increasing incidence of IHD at younger ages in regions like South Asia.19,20 East Asia (composed mostly of China) was another region with an IHD mortality increase in our analysis: in an earlier GBD study analysis of cholesterol trends, East Asia was among the few regions that experienced an increase in mean cholesterol after 1980.21 However, not all IHD epidemics are the same; there are past examples of IHD mortality declines in the face of adverse cholesterol or tobacco trends.22 Our analysis shows that, at a global level, traditional risk factors like tobacco smoke, high cholesterol, and high blood pressure play a central role in explaining regional differences in IHD mortality rates. Because no causal direction was specified and patterns of alcohol use were not distinguished (ie, binge or heavy compared with moderate alcohol consumption), our analysis did not accurately characterize the association of alcohol consumption with IHD. Regional air pollution level was not a significant covariate in the IHD mortality models, but epidemiological research has established air pollution as a risk factor for IHD,23 and its contribution will be explored in subsequent GBD analyses.

The association of lower regional economic and educational status with higher IHD rates suggests that many regions are undergoing an epidemiological transition to higher IHD death rates often associated with economic development. The populations of many of the transitioning regions (eg, South and East Asia, Latin America/Tropical [Brazil], and North Africa/Middle East) are enormous, and the continued development of these regions depends in part on successfully addressing the threat of cardiovascular disease. To succeed in stemming the tide of IHD mortality in younger adults in the 21st century, as many high-income regions did during the last decades of the 20th century, low- and middle-income regions may need to develop new approaches, emphasizing improved healthcare delivery infrastructure, universal health insurance and affordable essential medicines, and selected population- wide prevention interventions.24,25 Along with the public health community's emphasis on prevention, the impact of improved access to acute cardiac care should not be forgotten. Aspirin and a β-blocker for all acute myocardial infarctions and revascularization using low-cost thrombolytic for ST-elevation myocardial infarctions are often life-saving and may be affordable in low-resource settings.26

The strengths of this analysis of global trends in IHD mortality were the collection of a comprehensive set of national mortality data from a variety of sources, adjustments for biases introduced by ICD version changes and for death registration coding practices, and methods for accounting for and describing covariate parameter and statistical model selection uncertainty. Limitations of the analysis include incomplete data for many regions, especially sub-Saharan Africa, and the ecological nature of the associations found between covariates and IHD mortality. Unexpectedly, diabetes mellitus contributed more to male models than to female models, findings that may be explained by the inclusion of nontraditional IHD predictor covariates in the models that absorbed some of these covariates’ effects, or differential competing risk with other causes of death in males in comparison with females.

Implications

The decline in IHD mortality in high-income regions since 1980 is a success story. More troubling are the very high IHD mortality rates in Eastern Europe and Central Asia in 2010, and increased IHD mortality occurring in relatively young adults in South Asia. IHD prevention in the 21st century must extend the control of established risk factors from high- income to low- and middle-income regions while addressing newer social and behavioral determinants of IHD mortality observed in developing regions.

Supplementary Material

01

CLINICAL PERSPECTIVE.

Ischemic heart disease (IHD) leads to lost life-years and disability in high-, middle-, and lower-income regions and is the world's leading cause of death. Monitoring the trends in IHD mortality in diverse world regions requires analyzing a variety of data sources and using statistical modeling that accounts for sparse data in some regions. The Global Burden of Disease 2010 Study estimated IHD mortality in 21 world regions. Since 1980, age-standardized IHD mortality has declined in most world regions, particularly high-income regions. During the same period, age-standardized IHD mortality increased in Eastern Europe, Central Asia, and South Asia. When estimated by using a standard method, age-standardized IHD mortality has trended favorably in most regions since 1980, but unfavorably in a few others. The causes of rising rates in IHD hot-spot regions merit more detailed investigation. Prevention and acute care quality improvements are needed in low- and middle- income regions, where IHD patients die at relatively young ages.

Acknowledgments

We sincerely thank the many study participants and investigators of the studies contributing data to this analysis.

Sources of Funding

This research was supported by the Bill and Melinda Gates Foundation, an American Heart Association Postdoctoral Fellowship to Dr Roth, and US National Heart, Lung, and Blood Institute award K08 HL089675-01A1, and a Columbia University Irving Scholarship to Dr Moran.

Footnotes

Disclosures

The perspectives expressed in this article are those of the authors and do not necessarily represent the views of the National Institutes of Health, Department of Health and Human Services, or any other government entity.

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