Central Asia has the highest rates of cardiovascular disease (CVD) mortality of all regions globally, driven by a heavy burden of ischemic heart disease across the region, while the High-Income Asia-Pacific region, made up of Japan, Brunei, South Korea and Singapore, has the lowest global rates, according to data from the Global Burden of Cardiovascular Diseases (GBD) study.

The report – published in the Dec. 20/27 special issue of the Journal of the American College of Cardiology – is the latest update to the multinational GBD study, which aims to comprehensively characterize mortality and other health measures across 204 countries and territories.

The study, funded by the Bill and Melinda Gates Foundation, is led by researchers from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. The latest update from the initiative, led by Megan Lindstrom, PhD, from IHME, highlights 21 global regions, each with 2 pages of data presented in a graphic-rich almanac style.

The report is accompanied by an introductory article, led by Muthiah Vaduganathan, MD, MPH, from the Brigham and Women’s Hospital and Harvard Medical School, Boston, which highlight the leading global modifiable cardiovascular risk factors, their contribution to disease burden, and recent advances related to their control and prevention.

According to the report, the Central Asia region (Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Mongolia, Tajikistan, Turkmenistan, Uzbekistan) had the highest age-standardized CVD mortality rate among all GBD regions, at 516.9 deaths per 100,000 – 6.8-times higher than the region with the lowest mortality rate, high-income Asia Pacific (76.6 per 100,00).

Meanwhile, Australasia (Australia, New Zealand) had the largest percent reduction in age-standardized CVD mortality rate since 1990 (64.2%), decreasing from 285 deaths per 100,000 to 102.2 deaths per 100,000.

Central Asia in focus

The high burden of ischemic heart disease in Central Asia (306.6 deaths per 100,000; 5,128.4 disability-adjusted life years [DALYs]) was a primary driver for the region’s overall high incidence of CVD mortality in 2021 – with Kazakhstan, Azerbaijan and Tajikistan leading the way in age-standardized mortality rates per 100,000.

Beyond ischemic heart disease, the team reported that ischemic stroke (89.8 per 100,000), intracerebral hemorrhage (56.3 per 100,000), and hypertensive heart disease (27.1 per 100,000) had the highest mortality rates, and DALYs (1,483.2 vs 1,129.6 vs 421.3, respectively).

Non-rheumatic valvular heart disease had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (410.8%).

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 52.7%. Other important CVD risks noted include diet, high LDL-cholesterol (LDL-C), ambient particulate matter pollution, smoking, high body-mass index (BMI), low temperature and household air pollution from solid fuels.

High-Income Asia Pacific and Australasia lead the way

While the CVD burden was highest in Central Asia, the GBD report found that it was lowest in the High-Income Asia Pacific, where overall CVD deaths were reported to be 76.6 deaths per 100,000, driven particularly by a low incidence of ischemic heart disease and ischemic stroke in Japan, South Korea and Singapore.

Aortic aneurysm had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (58.8%) – with a 2021 mortality rate of 4.5 per 100,000 – while hypertensive heart disease had the largest percent decrease (71.2%) – with a 2021 mortality rate of 3.1 per 100,000.

After ischemic heart disease (475.8 DALYs) and stroke (ischemic stroke, 322.9; intracerebral hemorrhage, 247.6; subarachnoid hemorrhage, 134.0), aortic aneurysm had the highest age-standardized DALY rate (75.1).

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of CVD DALYs at 42.8% – other risk factors included dietary patterns, smoking, and high LDL-C.

Meanwhile, Australasia was reported to have the largest percent reduction in age-standardized CVD mortality rate since 1990 (64.2%), decreasing from 285 to 102.2 deaths per 100,000.

Endocarditis had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (133.3%) – with a 2021 rate of 1.2 per 100,000 – while ischemic heart disease had the largest percent decrease (71.8%) – with a 2021 rate of 50.6 per 100,000.

After ischemic heart disease (806.9), ischemic stroke (241.6) and intracerebral hemorrhage (127), the residual group of other CVD had the highest age-standardized DALY rate (144.6).

The modifiable risk factors with the biggest impact on DALY per 100,000 were metabolic factors including high systolic blood pressure, high LDL-C and high BMI. In fact, high systolic blood pressure accounted for the largest proportion of CVD DALYs at 38.4%.

Environmental risks such as ambient particulate matter pollution were significantly lower in Australasia, however behavioral risks including diet, smoking, and alcohol use were all noted to contribute to the burden of CVD in Australasia.

South Asia burden

According to the GBD study, age-standardized CVD mortality rates in 2021 for South Asia ranged from 248.6 per 100,000 in Bhutan to 350.9 per 100,000 in Pakistan.

Lower-extremity peripheral arterial disease had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (61.9%) – with a 2021 rate of 0.3 per 100,000 – while rheumatic heart disease had the largest percent decrease (51.2%) – with a 2021 rate of 15.3 per 100,000.

After ischemic heart disease (3,237.4) and stroke (ischemic stroke, 710.6; intracerebral hemorrhage, 938.1) rheumatic heart disease had the highest age-standardized DALY rate (448). However, when looking at deaths per 100,000 rheumatic heart disease (15.3 per 100,000) was fourth behind ischemic heart disease (152.8), ischemic stroke (42.2), intracerebral hemorrhage (39.7), and hypertensive heart disease (17.1).

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 45.6%. Other modifiable risk factors shown to be a significant contributor to overall CVD burden included diet, high LDL-C, smoking, household air pollution from solid fuels, ambient particulate matter pollution, high fasting glucose, and lead exposure.

Southeast and East Asia in focus

In East Asia, age-standardized CVD mortality rates in 2021 ranged from 94.2 per 100,000 (Taiwan) to 359.9 per 100,000 (North Korea) in 2021 – a 3.8-fold difference across the region.

Ischemic heart disease was responsible for the both the highest mortality rate (112.7 per 100,000) and highest DALYs (1,776.1) in the region – with intracerebral hemorrhage (70.8 deaths per 100,000; 1,326.4 DALYs) and ischemic stroke (65.4 deaths per 100,000; 1,134.5 DALYs) following. These were driven by comparatively higher rates in North Korea – particularly for ischemic heart disease and intracerebral hemorrhage.

Aortic aneurysm had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (45.3%) – with 0.5 deaths per 100,000 in 2021 – while rheumatic heart disease had the largest percent decrease (72.5%) – with 2021 deaths reported to be 4.3 per 100,000.

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 52.0%, however both behavioral risks such as diet and smoking, and environmental risks including ambient particulate matter pollution and lead exposure were reported to contribute to the CVD burden in the region.

Meanwhile, CVD mortality rates in Southeast Asia ranged from 124.9 (Thailand) to 421.6 per 100,000 (Laos). After ischemic heart disease (2,303.8) and stroke (ischemic stroke, 1,226.1; intracerebral hemorrhage, 1,871.4) hypertensive heart disease had the highest age-standardized DALY rate (435.5).

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 56.9%, while diet, smoking and high LDL-C all contributed to the CVD burden.

CVD in Oceania

The GBD study reported that age-standardized CVD mortality rates in Oceania ranged from 242.9 per 100,00 in Tonga to 721.7 per 100,000 in Nauru – a threefold difference regionwide.

Ischemic heart disease was responsible for the highest CVD burden in the region, with a 171.9 per 100,000 death rate and 3,684 DALY reported, followed by intracerebral hemorrhage (105.9 deaths per 100,000; 2340.4 DALYs).

Lower-extremity peripheral arterial disease had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 (31.3%) – with a 2021 rate of 0.1 per 100,000 – while rheumatic heart disease had the largest percent decrease (45.2%) – with a 2021 rate of 11 per 100,000.

Among all CVD risks, high systolic blood pressure accounted for the largest proportion of DALYs at 38.5%. Other risk factors contributing to CVD burden in the region include diet, household air pollution from solid fuels, smoking, high LDL-C, and ambient particulate matter pollution.

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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