Millions of Lives Lost to CVD Each Year: ‘Almanac’ Updates Global Burden

A comprehensive look at cardiovascular disease around the world, from 1990 to 2022, provides sobering data that, despite some progress, the number of deaths due to CVD reached nearly 20 million last year—some preventable and some related to aging.

This is the second such “almanac” to emerge from the Global Burden of Cardiovascular Diseases Collaboration, which formed in 2020 as an alliance among the Journal of the American College of Cardiology, the Institute for Health Metrics and Evaluation at the University of Washington, and the National Heart, Lung, and Blood Institute. As reported by TCTMD, a previous version was published in 2022.

The 2023 report, like the last, derives data from the Global Burden of Disease (GBD) Study. It covers cardiovascular conditions and risk factors across 21 global regions that include 204 countries and territories. The 124-page document was published online yesterday.

“What we’re doing here is taking the results of the [GBD] work and making it readily available for the audience of the Journal of the American College of Cardiology,” said senior author Gregory A. Roth, MD, MPH (University of Washington, Seattle).

The goal, he told TCTMD, is to get this vast amount of information about where the world’s headed into the hands of clinicians and researchers so that they can make use of it in their own work. For policymakers, too, it’s important to have evidence when deciding what steps to take, said Roth. “Our hope is to actually put that information in front of decision-makers.”

In an introduction that accompanies the new report, Roth, George A. Mensah, MD (National Institutes of Health, Bethesda, MD), and Valentin Fuster, MD, PhD (Icahn School of Medicine at Mount Sinai, New York, NY, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain), acknowledge that awareness doesn’t always translate into action.

“We know enough to prevent and control most CVD; however, knowing is not enough. We must also take action to disseminate promising practices and implement evidence-based interventions that constitute guideline-directed management of CVD and risks,” they write, emphasizing the need for strategies that reach all the world’s populations and communities, encompassing those that have historically flown under the radar.

For anyone who’s trying to better understand how the common risks that we grapple with in clinical practice, like metabolic risk factors, stack up against things like air pollution or changes in climate or changes in diet, we have [those details]. Gregory A. Roth

The report, by design, approaches data from the population level. Though broad, these details can be useful in counseling individual patients, Roth explained. “For anyone who’s trying to better understand how the common risks that we grapple with in clinical practice, like metabolic risk factors, stack up against things like air pollution or changes in climate or changes in diet, we have [those details]. . . . I don’t know that clinicians always trust that broader range of risks. I think that can be quite informative.”

Additionally, clinicians as advocates for their patients can play a role in developing policies to address CVD, Roth noted.

An Uneven Burden

The introduction highlights several main themes to the report.

First, there’s an increase in death due to CVD around the globe. While the age-standardized CVD mortality dropped by a relative 34.9% between 1990 and 2022 (from 358.4 to 233.2 per 100,000 people), the annual number of deaths increased from 12.4 million to 19.8 million. This reflects “global population growth and aging and the contributions from preventable metabolic, behavioral, and environmental risks,” the authors say, citing not only patient-related factors but also exposure to air pollution.

Cardiometabolic risks are growing, as well, the report notes. They highlight elevations in blood pressure, LDL cholesterol, body mass index, and fasting plasma glucose and kidney dysfunction as action points that can be addressed at individual and societal levels. Most influential was high systolic blood pressure, which made the largest contribution to CVD disability-adjusted life-years (DALYs), at 2,564.9 per 100,000 globally.

Importantly, the authors stress, the burden of CVD isn’t shared equally around the world. Age-standardized CVD mortality rates per 100,000 people in 2022 were nearly sixfold higher in Eastern Europe than in high-income Asia Pacific regions (432.3 vs 73.6). The age-standardized prevalence of CVD per 100,000 people was highest in Central Asia and lowest in South Asia (11,342.6 vs 5,881.0). “These marked variations have their roots in multiple complex, upstream, interrelated factors” that aren’t yet fully understood but relate to socioeconomics, culture, environment, healthcare delivery, behavior, and more, the introduction notes.

Roth and colleagues say the outsized impact of CVD on low- and middle-income countries (LMICs) is a major concern. “More than 75% of the global CVD burden is found in the LMICs in Oceania, Eastern and Central Europe, sub-Saharan Africa, North Africa and the Middle East, the Caribbean, and East and South Asia,” they write. “An important driver of this disproportionate burden is population growth and aging, coupled with the continuing epidemiologic transition leading to a rising burden of noncommunicable diseases such as CVD and related risk factors.”

And lastly, there’s a bit of good news: a “dramatic” 65.1% decline between 1990 and 2022 in CVD-related DALYs attributed to household air pollution from solid fuels. Environmental risks like this, as well as ambient particulate matter pollution, lead exposure, and nonoptimal temperatures (both low and high), merit close scrutiny, the report urges. “Practices and policies that help sustain these declines, especially in the context of adverse climate change impact, will play important roles in continuing the reductions in attributable CVD mortality.” Wider use of clean cookstoves, for instance, is a safe and effective strategy for tackling household air pollution.

Compared with the 2022 document, the 2023 version has evolved to include more data from the years studied (since some data sources lag behind others) and more-refined statistical methods. It’s also the first to include CVD-related numbers from the COVID-19 era.

“People had a lot of hypotheses about how coronary artery disease in particular and cardiovascular disease in general might have been affected by the pandemic. And the reality is we didn’t see as many changes as you would anticipate. Now, that doesn’t mean that COVID doesn’t lead to people dying through worsening their preexisting cardiovascular disease or even causing cardiovascular disease—we know that COVID-19 causes cardiovascular disease. But that’s not what we’re asking here,” which is whether there were noticeable changes to the big picture on a global scale, Roth specified. The pandemic, though devastating in many ways, did not alter the larger trends, he added. “We’re really struggling with this rising tide of cardiovascular disease.”

Another key revision relates to how ischemic heart disease is estimated. Previously, it was an aggregate of patients with and surviving MI, those with stable angina, and those with ischemic cardiomyopathy. Stable angina, in this iteration, was replaced by significant CAD (defined as a > 50% epicardial coronary stenosis, history of coronary revascularization, inducible myocardial ischemia based on diagnostic testing, or past MI). As a result, the estimated prevalence of ischemic heart disease is now 20% greater at the global level compared with prior GBD analyses.