Mortality rates linked with hypertensive heart disease have increased the most out of any cardiovascular disease (CVD) in the United States and Canada since 1990, while ischemic heart disease is the biggest disease burden in all regions of the Americas, according to the new Global Burden of Cardiovascular Diseases (GBD) report.

The latest findings – published in the Dec. 20/27 special issue of the Journal of the American College of Cardiology – are based on the multinational collaborative GBD study including more than 8,000 collaborators around the world, estimating disease rates at subnational, national, regional and global level. The extensive global data set spans 31 years' worth of records on the burden of cardiovascular disease from 1990 to 2021, as attributable to 88 risk factors.

Commenting on the report, Valentin Fuster, MD, PhD, an author of the paper and editor-in-chief of JACC said, “It is truly exciting to see this multi-year Global Burden of Cardiovascular Diseases Collaboration culminate into a dedicated issue of the Journal to inform the global cardiovascular community.

“This issue focuses both on the modifiable risk factors, as well as the global cardiovascular disease and death rates in 21 regions across the world,” added Fuster, who is also director of Mount Sinai Heart and physician-in-chief of The Mount Sinai Hospital.

Data from North America revealed that hypertensive heart disease had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (53.3% higher incidence), with a 2021 mortality rate of 10.8 per 100,000. Meanwhile rheumatic heart disease-related mortality has decreased by the biggest percentage (61.2% lower incidence) over the same period, with a 2021 mortality rate of 0.9 per 100,000, noted the team led by Megan Lindstrom, PhD, from the Institute for Health Metrics and Evaluation at the University of Washington.

The largest increase in the whole Americas region was in Andean Latin America (Bolivia, Ecuador and Peru) where the incidence of lower-extremity peripheral arterial disease grew by 111.9% since 1990 – though such an increase was for a relatively rare cause of death, with a 2021 mortality rate of 0.2 per 100,000.

Ischemic heart disease burden driven by high blood pressure

Across all Americas regions, ischemic heart disease was found to be the biggest burden, both in terms of deaths and disability-adjusted life years (DALYs;, indeed, the GBD survey reported a 2021 mortality rate ranging from 61.6 per 100,000 (1,123.1 DALYs) in Southern Latin America to 119.6 per 100,00 (2,391.1 DALYs) in the Caribbean. High systolic blood pressure and dietary risks were listed as the top modifiable risk factors for all six regions in the Americas.

Writing in an accompanying introductory article, researchers led by Muthiah Vaduganathan, MD, MPH, from Brigham and Women’s Hospital and Harvard Medical School, Boston, noted that high systolic blood pressure – which has been particularly linked to ischemic heart disease and stroke-related deaths – remains the leading modifiable risk factor globally for attributable premature cardiovascular deaths, accounting for 10.8 million (95% confidence interval [CI]: 9.15-12.1 million) cardiovascular deaths and 11.3 million (95% CI: 9.59- 12.7 million) deaths overall in 2021.

“Taken together, these data underscore the importance of public health strategies to promote early screening, detection, and treatment of hypertension. Even after diagnosis, traditional step-wise sequencing of prescribing pharmacotherapies may lead to treatment inertia and slow early effective blood pressure control,” they said.

High-Income North America

According to the GBD report, age-standardized CVD mortality rates in High-Income North America (defined as Canada, Greenland and the United States) for 2021 ranged from 102.1 per 100,000 in Canada to 224.8 per 100,000 in Greenland 2021 – a 2.6-fold difference across the region. The age-standardized CVD mortality rates were reported as 150.8 for the U.S.

After ischemic heart disease (1,412.6 DALYs) and ischemic stroke (339.0 DALYs), hypertensive heart disease had the highest age-standardized DALY rate of 226.4. Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 40.5%, followed by dietary risks, high LDL-cholesterol, and smoking.

Caribbean

According to GBD data, age-standardized CVD mortality rates in the Caribbean ranged from 102.2 per 100,00 (Puerto Rico) to 479.2 per 100,000 (Haiti) in 2021 – a 4.7-fold difference in the region.

Ischemic heart disease represented the largest overall burden in the region, where the overall burden for the region was reported to be 119.6 deaths per 100,00 and 2,391.1 DALYs, in 2021.

Endocarditis had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (34.7%) – with a 2021 mortality rate of 1.0 per 100,000 – while rheumatic heart disease had the largest percent decrease (43.9%) – with a 2.0 per 100,000 mortality rate reported.

After ischemic heart disease (2,391.1 DALYs) and stroke (Ischemic stroke, 641.4 DALYs; intracerebral hemorrhage, 821.7) hypertensive heart disease had the highest age-standardized DALY rate (404.3).

Meanwhile, high systolic blood pressure was the modifiable risk factor to account for the largest proportion of DALYs (46.8%), with diet, high LDL-cholesterol and smoking following.

Latin American Burden

The GBD report separated Latin America into four regions: Central Latin America (Colombia, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Venezuela), Andean Latin America (Bolivia, Ecuador, Peru), Tropical Latin America (Brazil, Paraguay) and Southern Latin America (Argentina, Chile, and Uruguay).

Vaduganathan and colleagues noted that in recent years, cases of chronic kidney disease (CKD) “of unknown cause” have increased among agricultural workers in some regions of the world – notably in parts of Latin America.

“The exact mechanism underlying this illness is uncertain but is thought to potentially be related to toxins (such as pesticide exposure), heat exposure, or potential infectious agents,” they said.

In 2021, 1.87 million (95% CI: 1.44-2.34 million) cardiovascular deaths and 3.47 million (95% CI: 2.93-4.00 million) deaths overall were attributable to reduced kidney function. All-cause DALYs due to kidney dysfunction were 1,040 per 100,000 (95% CI: 935-1,180 per 100,000) in 2021.

Central Latin America

According to the GBD report, age-standardized CVD mortality rates in Central Latin America ranged from 115.6 per 100,000 (Costa Rica) to 330.1 per 100,000 (Honduras) in 2021 – a 2.9-fold difference across the region.

After ischemic heart disease (107.9 deaths per 100,000, 1,941 DALYs) and stroke (ischemic stroke, 19.6 deaths per 100,000, 324.6 DALYs; intracerebral hemorrhage, 14 deaths per 100,000, 328.5 DALYs), hypertensive heart disease had the next-highest mortality rate (10.1 per 100,000) and age-standardized DALY rate (159.2).

Endocarditis had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (47.9%) – with a 0.6 per 100,000 mortality rate in 2021 – while rheumatic heart disease had the largest percent decrease (83.7%) – reporting a 0.5 per 100,000 death rate in 2021.

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 48.1% followed by diet, smoking, and high LDL-cholesterol.

Andean Latin America

In Andean Latin America, age-standardized CVD mortality rates varied from 101.1 per 100,000 (Peru) to 191.3 per 100,000 (Bolivia) in 2021 – a 1.9-fold difference.

Lower-extremity peripheral arterial disease had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (111.9%), while rheumatic heart disease had the largest percent decrease (67.5%).

Ischemic heart disease (64.2 deaths per 100,000, 1,172.5 DALYs), and all forms of stroke (ischemic stroke, 19.6 deaths per 100,000, 323.3 DALYs; intracerebral hemorrhage, 15.8 deaths per 100,000, 385.2 DALYs; subarachnoid hemorrhage, 6.4 deaths per 100,000, 208.2 DALYs) represented he biggest cardiovascular burden in the region. Beyond ischemic heart disease and stroke, hypertensive heart disease had the highest age-standardized DALY rate of 154.4 and had a higher mortality rate than subarachnoid hemorrhage (9.3 vs 6.4 deaths per 100,000).

High systolic blood pressure accounted for the largest proportion of DALYs at 39.0%, with diet, ambient particulate matter pollution, high LCL-cholesterol, high BMI, and smoking providing further risk factors of note.

Tropical Latin America

For Tropical Latin America, overall age-standardized CVD mortality rates in 2021 ranged from 162.2 per 100,000 in Brazil to 204.9 per 100,000 in Paraguay – a 1.3-fold difference between the two nations.

After ischemic heart disease (67.7 deaths per 100,000, 1,439.6 DALYs) and stroke (ischemic stroke, 31.9 deaths per 100,000, 513.4 DALYs; intracerebral hemorrhage, 17.7 deaths per 100,000, 438.0 DALYs), hypertensive heart disease had the highest death rate (13.3 per 100,000) and age-standardized DALY rate 229.2.

Endocarditis had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (35.4%), while stroke had the largest percent decrease (61.1%).

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 45.3%, while diet, smoking, high LDL-cholesterol and high BMI were listed as other risk factors.

Southern Latin America

Age-standardized CVD mortality rates in Southern Latin America ranged from 118.8 per 100,000 (Chile) to 172.8 per 100,000 (Argentina) in 2021 – a 1.5-fold difference.

Other cardiovascular and circulatory diseases, including residual conditions, represented the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (77.7%) – to 8.7 deaths per 100,00 in 2021 – while rheumatic heart disease had the largest percent decrease (70.7%) – reporting a 2021 death rate of 1.4 per 100,000.

After ischemic heart disease (61.6 deaths per 100,000, 1,123.1 DALYs) and stroke (ischemic stroke, 24.2 deaths per 100,000, 401 DALYs; intracerebral hemorrhage, 16.7 deaths per 100,000, 392.8 DALYs), the residual group of other CVD had the highest age-standardized DALY rate (257.6) while hypertensive heart disease was responsible for the next highest mortality rate (15.9 per 100,000).

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 42.0%, while diet, high LDL-cholesterol, smoking, high body mass index, were also noted as risk factors.

Will Chu contributed to this report.

Sources:

Vaduganathan M, Mensah GA, Turco JV, et al. The Global Burden of Cardiovascular Diseases and Risk: A Compass for Future Health. J Am Coll Cardiol 2022;80:2361-2371.

Lindstrom M, DeCleene N, Dorsey H, et al. Global Burden of Cardiovascular Diseases and Risks Collaboration, 1990-2021. J Am Coll Cardiol 2022;80:2372-2425.

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