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A new multinational report details the substantial burden of cardiovascular disease (CVD) worldwide and spotlights the importance of collective action to address the modifiable risk factors driving these diseases.

Published today in a special issue of the Journal of the American College of Cardiology, the report uses a graphic-rich, almanac style to present data on 18 specific CV conditions and 15 risk factors across 21 global regions, and serves as an update to the Global Burden of Diseases (GBD) 2019 study from the Global Burden of Cardiovascular Diseases Collaboration.

“This is an update, but it’s a huge expansion of that work,” senior author Gregory A. Roth, MD, MPH, que es fennel told theheart.org | Medscape Cardiology. “First of all, it’s coming in this Almanac format with over 50 pages of detailed tables and figures, so that people in different parts of the world can really zoom right to the estimates and the picture of cardiovascular disease risk for their region of the world.”

It also looks specifically at the way behavior, metabolic, and environmental risks contribute to CVD, both globally and for all regions of the world, said Roth, director of the Cardiovascular Health Metrics program at the Institute for Health Metrics and Evaluation, University of Washington, Seattle.

“That’s really important because if you understand the risks that drive cardiovascular disease, then you understand the levers that you can use to try and prevent it.”

To estimate global CVD prevalence and produce country-level estimates, the investigators leveraged data from 1990-2021 in the GBD study. Deaths were identified using vital and sample registration data.

Ischemic heart disease was identified as the leading cause of CV mortality in 2021, accounting for 9.4 million deaths in 2021 and 185 million disability-adjusted life years (DALYs), followed by ischemic stroke (3.8 million deaths) and intracerebral hemorrhage (3.4 million deaths).

Central Asia had the highest age-standardized CVD mortality rate at 516.9 deaths per 100,000 persons. This is 6.8 times higher than high-income Asia-Pacific, the GBD region with the lowest aged-standardized mortality rate, at 76.6 deaths per 100,000.

Since 1990, Australasia had the largest percentage drop in CVD mortality (64.2%), decreasing from 285 to 102 deaths per 100,000 in 2021.

Mortality rates in high-income North America ranged from 102.2 to 224.8 per 100,000 in 2021, a 2.6-fold difference, and ranged from 138.7 to 585.8 per 100,000 in Central Europe, a 4.2-fold difference.

High BP Retains its Grip

Among all CVD risks, high systolic blood pressure (BP) remains the leading cause of premature CV deaths, accounting for 10.8 million CV deaths and 11.3 million deaths overall in 2021.

Regions with the highest rates of CVD burden due to elevated systolic BP were Central Asia, Central Sub-Saharan Africa, and Eastern Europe, accounting for 52.7%, 55.7%, and 49.6% of DALYs, respectively.

“Worldwide, if you had to lump everyone together and say what are the areas where we could really have a huge impact? It would have to be high blood pressure,” George A. Mensah, MD, study author and director of the Center for Translation Research and Implementation Science at the National Health, Lung, and Blood Institute, said in an interview.

“There are places in the world where control rates are as low as 20%, meaning 8 out of 10 people with high blood pressure don’t have it under control,” he said. “And we have very good evidence that controlling hypertension prevents a ton of stroke and a ton of heart failure.”

Although it would be helpful to provide more education to physicians to overcome the clinical inertia surrounding treatment intensification, he said the mistake that’s often made is to single out one group to assign blame — the food industry, physicians, and, worse yet, patients. “None of these is really true in silo, it’s really a combination.”

Beyond Hypertension

Mensah also cautioned against focusing only on hypertension as a modifiable risk factor, observing that high tobacco and alcohol use and dietary risks continue to play a major role in CVD rates in many regions.

DALYs per 100,000 attributable to high alcohol use were higher in Eastern Europe than anywhere else in the world in 2021, whereas rates were lowest in North Africa and the Middle East. Globally, there were 407,000 CV deaths and nearly 1.9 million deaths overall as a result of high alcohol use.

In 2021, just over 3 million cardiovascular deaths and 7.6 million deaths overall were attributed to tobacco use. All-cause DALYs were 2460 per 100,000 persons.

Implementation of such initiatives as the World Health Organization MPOWER program, national telephone quit lines, and improved primary care counseling have been linked with lower tobacco use, the authors note.

Low intake of healthy foods like fruits, vegetables, legumes, and whole grains and overconsumption of red and processed meats, sugar-sweetened beverages, and sodium is a major driver of CV risk in many parts of the world, accounting for 6.6 million CV deaths and 8 million deaths overall in 2021. All-cause DALYs due to dietary risk were 2340 per 100,000 persons.

Mensah said the current analysis was not designed to tease out the impact of the COVID-19 pandemic on global CV health; however, a recent state-of-the art review by Mensah and Roth reported that the number of deaths attributed to CVD in 2020 was similar to or less than in recent years in a number of countries, except in Ecuador, Mexico, and Russia.

Air Pollution, a Rising Risk

“Importantly, we see air pollution in the top three [drivers of CVD] now, which was not the case in the past,” senior author Roth noted.

In many parts of the world, ambient particulate matter and indoor air pollution, predominantly from fuel and cooking stoves, represent the leading environmental risk factors for premature CVD and mortality. Air pollution accounted for about 4.8 million CV deaths and 8.5 million deaths overall in 2021.

“So, it’s really important that we think about risk factors in a particular location because we really want public health systems to be tailored to those kinds of unique patterns, things we might not see in the United States like indoor cooking stoves,” he said.

Although global preparedness initiatives are needed to buffer the cardiovascular effects of weather-related extremes, more public health initiatives are also needed on milder but nonoptimal ambient temperatures, which account for far greater mortality burden, according to the authors. In 2021 alone, the all-cause DALYs due to nonoptimal temperatures were 420 per 100,000 persons.

Moving the Needle

The analysis helps move public health forward by not only tracking cardiovascular diseases and risks but allowing stakeholders to see if the interventions being invested in are making a difference, Roth said.

“Benchmarking our progress with analyses like this is really important,” he said. “Not only do governments and health systems need to pay attention to these kinds of efforts, but citizens need to as well, so they can advocate for good health in their society. Cardiovascular disease is one of the major determinants of whether we’re living in a health country or not.”

In addition, more can be done to help educate people beginning at an early age on how to adopt a healthy lifestyle to avoid developing CVD risk factors, let alone the diseases they cause, and to provide greater access to healthcare and existing treatments, Roth added.

“The World Health Organization has been promoting pathways to achieve universal health coverage. We do not have it in the United States, and we do not have it in most countries in the world,” Roth said. “And I think we will only start to see countries significantly improve their cardiovascular health, as we measured in this almanac, when we see countries developing robust equitable health systems.”

The Global Burden of Disease study was funded by the Bill and Melinda Gates Foundation. The authors report having no relevant financial relationships.

J Am Coll Cardiol. Published online December 12, 2022. Introduction, Full text

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