Global Burden of Hypertensive Heart Disease and Attributable Risk Factors, 1990-2021: Insights from the Global Burden of Disease Study 2021

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Objective This study aims to assess the burden of HHD from 1990 to 2021, analyzing prevalence, mortality, and disability-adjusted life years (DALYs) stratified by age, sex, and Sociodemographic Index (SDI). Utilizing data from the Global Burden of Disease 2021 project across 204 countries and 21 regions, the study calculated age-standardized rates and evaluated risk factors for prevention priorities. Methods In 2021, there were 12.5 million HHD cases globally, resulting in 1.332 million deaths and 25.4622 million DALYs. Age-standardized rates were 148.3 for prevalence, 16.3 for deaths, and 301.6 for DALYs per 100,000 people, reflecting increases of 18.2% for prevalence but decreases for deaths (-22%) and DALYs (-25.8%) since 1990. Eastern Sub-Saharan Africa recorded the highest prevalence (291.8), while Bulgaria had the highest mortality (103.4) and DALY rates (1739.3). Results Age-specific trends showed that prevalence, deaths, and DALYs increased with age across genders, and at regional levels, DALYs decreased with higher SDI. Major contributing factors included high systolic blood pressure, metabolic risks, high body-mass index, unhealthy diet, alcohol use, and low fruit and vegetable intake. Conclusions Despite advances in management, HHD remains a global health concern, especially in low-SDI areas. Efforts focused on modifiable risks, like hypertension control and dietary improvements, are essential to mitigate the burden of HHD. Biological sciences/Computational biology and bioinformatics Earth and environmental sciences/Biogeochemistry Health sciences/Risk factors Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION Hypertensive heart disease, a cardiac dysfunction resulting from hypertension, has gradually emerged as a major global health concern. Based on data from the World Health Organization (WHO), hypertension is a significant risk factor for cardiovascular diseases, impacting the health of billions of people globally. Current studies suggest that hypertensive heart disease not only causes alterations in cardiac structure and function but is also closely associated with complications like heart failure, atrial fibrillation, and coronary heart disease. [1,2] There are significant differences in the epidemiological characteristics of hypertensive heart disease across different countries and regions, closely related to factors such as socioeconomic status, accessibility of medical resources, and public health policies. For example, studies have found that although high-income countries have a higher level of cardiovascular disease management, in low-income countries, due to a lack of medical resources, early screening and treatment for patients are often limited, leading to disease progression and an increased incidence of complications. [3] Additionally, women face a higher risk of cardiovascular complications after experiencing hypertension-related conditions such as pregnancy-induced hypertension. [4] This gender difference also varies across different regions, reflecting disparities in social culture and healthcare systems. [5] Globally, research on hypertensive heart disease is gradually increasing, but there is still a lack of systematic epidemiological data to comprehensively assess the impact of this disease on public health. Particularly in low- and middle-income countries, data on the epidemiological characteristics, prevalence, and mortality of hypertensive heart disease are relatively scarce, necessitating in-depth exploration. [6,7] Previous analyses, including the GBD 2017 study, revealed regional variations in the burden of HHD, with low- and middle-income countries experiencing disproportionately greater impacts due to limited healthcare resources and poor blood pressure control. [8] However, a more recent analysis of the GBD 2021 dataset offers an updated and broader view of these trends. It incorporates data from the COVID-19 pandemic period, which might have intensified cardiovascular risk factors worldwide.This study aims to clarify global, regional, and national patterns in HHD prevalence, mortality, and DALYs, as well as key attributable risk factors. METHODS Data Sources The 2021 GBD study offers a meticulous evaluation of health impairments associated with 369 diseases, injuries, and impairments, along with 88 risk factors, encompassing 204 nations and territories, through the utilization of the most recent epidemiological data and enhanced standardized approaches. In this investigation, the estimates and their 95% uncertainty intervals (UI) for prevalence, deaths, and DALYs related to HHD were derived from the GBD 2021 data. [9] ( http://ghdx.healthdata.org/gbd-2021 ) Additionally, the study employed the sociodemographic index (SDI), which is a metric that quantifies a region's sociodemographic development based on income, education, and fertility circumstances. [10] Furthermore, the University of Washington Institutional Review Board waived the necessity for informed consent to access the GBD data. [11] This research conformed to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). [12] Key Metrics HHD burden was quantified using prevalence, deaths, and DALY rates. DALYs were calculated as the sum of years of life lost (YLLs) due to premature mortality and years lived with disability (YLDs). Age-standardized rates were calculated using the global age structure to enable cross-country comparisons. [13] Attributable Risk Factors We assessed the contributions of high systolic blood pressure, high BMI, dietary risks (e.g., high sodium and low fruit/vegetable intake), and alcohol use to HHD burden. Comparative risk assessment methodologies incorporated relative risks from meta-analyses and systematic reviews. [14,15] Statistical Analysis All analyses were conducted using R (version 4.3.3). Uncertainty intervals (UIs) were computed based on 1,000 Monte Carlo simulations to account for data variability. RESULTS Table 1 Prevalence,deaths, and disability-adjusted life years (DALYs) of hypertensive heart disease in 2021, and the percentage change in the standardized rate per 100,000 population (ASRs) in the Global Burden of Disease regions from 1990 to 2021. Global Trends In 2021, the global prevalence of hypertensive heart disease (HHD) was approximated at 125.1 million instances (UI 117.3–132.8), signifying an 18.2% augmentation in contrast to 1990. The age-standardized prevalence rate of HHD stood at 148.3 per 100,000 individuals, demonstrating a moderate escalation over three decades. Global age-standardized death and DALY rates for HHD exhibited remarkable enhancements, with declines of 22.0% and 25.8% respectively between 1990 and 2021. The mortality rate in 2021 was 16.3 per 100,000 population, and the DALY rate was 301.6 per 100,000 population. (Table 1) Table 2 Prevalent cases of hypertensive heart disease in 1990 and 2021 and the percentage change in the age-standardised rates (ASRs) per 100,000, by location Table 3 Deaths due to hypertensive heart disease in 1990 and 2021 and the percentage change in the age-standardised rates (ASRs) per 100,000, by location Table 4 DALYs due to hypertensive heart disease in 1990 and 2021 and the percentage change in the age-standardised rates (ASRs) per 100,000, by location Regional level In 2021, the age-standardized point prevalence of HHD (per 100,000 population) reached its peak in Eastern Sub-Saharan Africa (291.8), followed by Western Sub-Saharan Africa (266.3), and North Africa and the Middle East (243.3). In contrast, the lowest rates were observed in High-income Asia Pacific (57.6), Australia and New Zealand (52.4), and Eastern Europe (42.8) (Table 1). The age-standardized mortality rate of HHD (per 100,000 population) was highest in Central Sub-Saharan Africa (66.3), Southern Sub-Saharan Africa (47.4), and Eastern Sub-Saharan Africa (42.6) in 2021. The lowest rates were found in High-income Asia Pacific (3), Australia and New Zealand (2.4), and Eastern Europe (7.4) (Table 1). Similarly, the age-standardized DALY rate of HHD (per 100,000 population) was highest in Central Sub-Saharan Africa (1213.1), Southern Sub-Saharan Africa (889.1), and Eastern Sub-Saharan Africa (786.2) in 2021. The lowest rates were recorded in Australia and New Zealand (38.8), High-income Asia Pacific (47.1), and Western Europe (111.1) (Table 1). Figures S1-S3 display the age-standardized point prevalence, mortality rate, and DALY rate of HHD in the Global Burden of Disease Study for all regions in 2021, respectively. From 1990 to 2021, the regions that witnessed the most significant increase in the age-standardized point prevalence of HHD were Australia and New Zealand (67%), High-income North America (64.2%), and Western Europe (53.3%). Conversely, the regions with the largest decrease were Central Latin America (-13%), East Asia (-10.9%), and Oceania (-7.6%) (Table 1). During the same period, the age-standardized mortality rate of HHD declined in most regions, with the most substantial decrease in High-income Asia Pacific (-71.8%), East Asia (-55.3%), and Central Latin America (-48.3%) (Table 1). From 1990 to 2021, the age-standardized DALY rate decreased in most regions, with the most significant reduction in High-income Asia Pacific (-70.4%), East Asia (-58.5%), and Central Latin America (-48.8%) (Table 1). The global number of prevalent cases of HHD rose from 125 million in 1990 to 148 million in 2021. In 1990, the highest number of prevalent cases of HHD was in South Asia, Central Asia, and China, and these regions continued to hold the top positions in 2021 (Table S1). The global number of deaths due to HHD decreased from 2.09 million in 1990 to 1.63 million in 2021. In 2021, the highest number of deaths was in Grenada, the Democratic Republic of the Congo, and Panama (Table S2). The number of DALYs due to HHD declined from 40.65 million in 1990 to 30.16 million in 2021. In 2021, the highest number of DALYs was in South Asia, China, and East Asia (Table S3). National level In 2021, the age-adjusted prevalence of HHD at the national level varied from 8.7 to 329.9 instances per 100,000 individuals. The highest age-adjusted prevalence rates of HHD were observed in the Cook Islands (317), the Bahamas (317.5), and Jordan (329.9), while the lowest estimates were noted in Belarus (8.7), Belgium (23), and Iceland (24.2) (Figure 1 and Table S1). The age-adjusted mortality rate of HHD at the national level in 2021 ranged from 1.1 to 103.4 cases per 100,000 people. The highest rates were recorded in Madagascar (77.6), Afghanistan (78.3), and Bulgaria (103.4), with the lowest rates in Belarus (1.1), Norway (2), and Belgium (21) (Figure 2 and Table S2). In 2021, the age-adjusted DALY rate of HHD at the national level ranged from 25 to 1739.3 cases per 100,000 people. The highest rates were seen in Madagascar (1509), Lesotho (1524.5), and Bulgaria (1739.3), while the lowest rates were observed in Belarus (25), Norway (27.4), and Belgium (29.8) (Figure 3 and Table S3). Age and Sex Patterns Number of prevalent cases globally and prevalence of HHD per 100 000 population, by age and sex in 2021. Lines indicate prevalent case with 95% uncertainty intervals for men and women(Figure 4 A);Number of deaths cases globally and prevalence of HHD per 100 000 population, by age and sex in 2021. Lines indicate prevalent case with 95% uncertainty intervals for men and women(Figure 4 B);Number of DALYs cases globally and prevalence of HHD per 100 000 population, by age and sex in 2021. Lines indicate prevalent case with 95% uncertainty intervals for men and women(Figure 4 C) Globally, in 2021, the age-specific prevalence, mortality, and DALY rates of HHD escalated with age in both genders (Figure 4). The incidence of cases in men surpassed that in women prior to the age of 69, while the incidence of cases in women exceeded that in men after the age of 70. The peak was attained in men and women who were aged 70 to 74. The quantity of deaths and DALYs in men was greater than that in women before the age of 64, and the number of deaths and DALYs in women was higher than that in men after the age of 65. The peak mortality rate in men and women was reached at the age of 80-90, and the peak DALY rate was achieved at the age of 70-74. Association with sociodemographic index Age standardised disability adjusted life year (DALY) rates of HHD for the 21 Global Burden of Disease regions by sociodemographic index, 1990–2021. Thirty-two points are plotted for each region and show the observed age standardised DALY rates from 1990 to 2021 for that region. Expected values, based on sociodemographic index and disease rates in all locations, are shown as a solid line. Regions above the solid line represent a higher than expected burden (eg, Central sub-saharan Africa) and regions below the line show a lower than expected burden (eg, Central Latin Americal) Generally, the age-standardized DALY rates for HHD in the 21 GBD regions decreased with increasing SDI (Figure 5). The age-standardized DALY rates in Central Sub-Saharan Africa, North Africa and Middle East, and Southern Sub-Saharan Africa were much higher than expected based on SDI for all years from 1990 to 2021. Despite the improvement in SDI over time, several regions, including Central Europe, Western Europe, and High-income North America, had an increase in age-standardized DALY rates from 1990 to 2021. It shows the relationship between age-standardized DALY rates and SDI at the country level in 204 countries and territories worldwide in 2021. Similar to regional trends, age-standardized DALY rates at the country level showed a decreasing trend with increasing SDI. Age-standardized DALY rates in Afghanistan, Madagascar, Bulgaria, Panama, and many other countries were much higher than expected based on SDI. The disability-adjusted life years (DALYs) caused by hypertensive heart disease (HHD) due to individual risk factors are approximately the same in different genders. The top 8 risk diets for hypertensive heart disease (HHD) are high blood pressure, high metabolic score, high BMI, high sodium diet, alcohol consumption,Low fruit intake, Low vegetable intake, and behavioral risks. DISCUSSION Major Trends in Global Disease Burden Globally, sub-Saharan Africa and Southeast Asia face the highest burden of disease. The high disability-adjusted life years (DALYs) and mortality rates in both regions suggest that infectious diseases, malnutrition, and poverty pose a long-term threat to public health [16–18] . Lack of nutrition is particularly acute in sub-Saharan Africa, resulting in a significant number of deaths and disease, particularly in low-and middle-income countries, [16] . Moreover, with the acceleration of urbanization and population growth, the spread of infectious diseases and the aggravation of malnutrition put the public health resources in these areas under great pressure [17] 。In comparing health status in low-and middle-income countries, high-income countries (e. g., Nordic, Australia and Canada) significantly reduced disease burden through an efficient healthcare system and successful public health policies. Public health spending and health systems responsiveness in these countries have played an important role in improving health status among low-income populations [19] . For example, there are differences in income in Canada and Australia, but public health policies in both countries partly alleviate these inequalities [20] . These regional differences reveal a trend of increasing importance for chronic diseases. In Central America and the Caribbean, the high incidence of chronic diseases (e. g., cardiovascular disease, diabetes) has a significant impact on healthspan, although the mortality rate is lower [21,22] . These chronic diseases not only affect the quality of life of individuals, but also cause significant stress on the public health system and the economy [23,24] . Age and Gender Disparities Age and sex have a profound influence on the distribution of disease burden. The results of 2021 have shown that the prevalence of disease and disability-adjusted life years (DALYs) have increased significantly with increasing age, with the burden of chronic disease becoming the main problem [25,26] .In China, the economic burden of chronic diseases has also attracted widespread attention, especially in the elderly group, where household economic pressure has significantly increased in [27] . Therefore, health policies and interventions targeting older populations need to focus more on the prevention and management of chronic diseases to reduce the disease burden and healthcare costs in the future [26,28] . The health burden of men was more pronounced at younger ages, mainly due to high-risk behaviors (e. g., smoking, drinking) and occupational exposure. This difference was particularly evident in disability-adjusted life years (DALYs) and mortality [29,30] . The generalizability of smoking and alcohol consumption coupled with high intensity occupational requirements in young men leads to higher health risk and greater burden of disease [31] . In older age, the health burden of women gradually approaches that of men, and chronic disease management becomes the key to health strategies in this stage. Research indicates that as women age, they experience an increasing prevalence of chronic conditions, which significantly impacts their overall health and quality of life [32] . This trend necessitates a focused approach to managing chronic diseases, particularly as women often face unique challenges related to their health literacy and access to care [33] . The Relationship Between SDI and Disease Burden In global health, the negative correlation between the level of socio-economic development (SDI) and disease burden further emphasizes the importance of economic development. Low SDI regions (e. g., sub-Saharan Africa) face high disability-adjusted life years (DALYs) burden due to infectious diseases and neonatal health problems [34,35] . However, the health challenges of some medium socio-economic development index (SDI) countries (such as Eastern Europe) have exceeded expectations, which is closely related to the health problems caused by the socioeconomic transition. This suggests that simply increasing SDI alone is not sufficient to fully address the disease burden. Studies have shown that economic development and medical expenditure are important factors in achieving high life expectancy, but the spread of modern diseases (e. g., obesity and diabetes) has a significant negative impact on life expectancy [36] . Therefore, region-specific health interventions and policies should consider these complex socioeconomic factors to effectively respond to the disease burden of [37] . Key Risk Factors and Regional Characteristics Behavioral and metabolic risk factors play a significant role in global disease burden, with notable regional differences: High-income countries : Behavioral risks (e.g., high-sodium diet, alcohol use) and metabolic risks (e.g., hypertension, high BMI) are major contributors, with chronic diseases such as cardiovascular conditions being dominant [38–40] . Sub-Saharan Africa : Despite lower metabolic risks, infectious diseases and malnutrition result in a significant health burden [41,42] . South Asia and Southeast Asia : Low fruit and vegetable intake are prominent behavioral risks, while hypertension and high BMI are emerging as critical health challenges [43,44] . Central Asia and Eastern Europe : Alcohol consumption and high-sodium diets are significant behavioral risks, while metabolic risks like hypertension and obesity directly contribute to high DALYs [45,46] . Studies show that levels of alcohol-related health hazards are higher in Eastern Europe than in Western Europe, and although historical and cultural factors have profound effects on drinking patterns, effective policy responses have been effective in some countries [45] . Globally, metabolic risks such as hypertension and high BMI are becoming increasingly prominent with economic development and lifestyle changes. Behavioral risks, however, reflect regional socioeconomic and cultural differences. These findings highlight the importance of tailored health interventions, such as promoting dietary and lifestyle improvements in high-income countries and strengthening infectious disease prevention and nutritional support in low-income regions. Limitations and Future Directions The analysis is constrained by variations in data quality across regions, which may lead to underestimation or overestimation of the disease burden in some areas. Furthermore, the growing prevalence of metabolic disorders (e.g., diabetes, chronic kidney disease) complicates the current health landscape. Future research should integrate these emerging risks to provide a more comprehensive assessment. CONCLUSION The significant regional, age, and gender disparities in global disease burden underscore the need for equity and precision in health strategies. Strengthening basic healthcare services and public health investments in low-SDI regions, improving chronic disease management in middle-SDI regions, and optimizing healthy lifestyles in high-SDI regions can effectively reduce the global disease burden. Declarations Clinical trial number : not applicable. Funding : Jiangsu Provincial Health Commission, Y12023027 Ethics approval and consent to participate the University of Washington Institutional Review Board waived the requirement for informed consent to access the GBD data. This research adhered to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Competing interests : The authors declare no competing interests. Data availability statement The data used for the analyses in the study are publicly available at https://ghdx.healthdata.org/gbd-results-tool. References Masenga SK, Kirabo A. Hypertensive heart disease: risk factors, complications and mechanisms. Front Cardiovasc Med. 2023;10:1205475. Published 2023 Jun 5. doi:10.3389/fcvm.2023.1205475 Westaby JD, Miles C, Chis Ster I, et al. Characterisation of hypertensive heart disease: pathological insights from a sudden cardiac death cohort to inform clinical practice. J Hum Hypertens. 2022;36(3):246-253. doi:10.1038/s41371-021-00507-6 Siu SC, Lee DS, Fang J, Austin PC, Silversides CK. New Hypertension After Pregnancy in Patients With Heart Disease. J Am Heart Assoc. 2023;12(10):e029260. doi:10.1161/JAHA.122.029260 Ackerman-Banks CM, Lipkind HS, Palmsten K, Ahrens KA. 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Estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa: a systematic review with meta-analysis. Sci Rep. 2024;14(1):6494. Published 2024 Mar 18. doi:10.1038/s41598-024-55730-1 Dixit AA, Azar KM, Gardner CD, Palaniappan LP. Incorporation of whole, ancient grains into a modern Asian Indian diet to reduce the burden of chronic disease. Nutr Rev. 2011;69(8):479-488. doi:10.1111/j.1753-4887.2011.00411.x Jemal A, Girum T, Kedir S, et al. Metabolic syndrome and its predictors among adults seeking medical care: A trending public health concern. Clin Nutr ESPEN. 2023;54:264-270. doi:10.1016/j.clnesp.2023.01.034 Jasilionis D, Leon DA, Pechholdová M. Impact of alcohol on mortality in Eastern Europe: Trends and policy responses. Drug Alcohol Rev. 2020;39(7):785-789. doi:10.1111/dar.13167 Pamukcu B. Profile of hypertension in Turkey: from prevalence to patient awareness and compliance with therapy, and a focus on reasons of increase in hypertension among youths. J Hum Hypertens. 2022;36(5):437-444. doi:10.1038/s41371-020-00480-6 Tables Table 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table14.docx Global21Regions1990to2021.csv Global21Regionschange.csv orderglobalandregions.csv Global21regions204countries.csv Global21regions204countrieschange.csv orderglobal21regions204countries.csv Global2021AgeandSex.csv SDI19902021.csv Riskfactor2021.csv Cite Share Download PDF Status: Published Journal Publication published 26 Apr, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 07 Apr, 2025 Reviews received at journal 06 Apr, 2025 Reviews received at journal 05 Apr, 2025 Reviewers agreed at journal 30 Mar, 2025 Reviewers agreed at journal 30 Mar, 2025 Reviewers agreed at journal 29 Mar, 2025 Reviewers invited by journal 28 Mar, 2025 Editor assigned by journal 28 Mar, 2025 Editor invited by journal 25 Mar, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6008871","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":436015029,"identity":"9341cbb5-4840-4baa-b871-7569712b1e96","order_by":0,"name":"Wu Xiao","email":"","orcid":"","institution":"the Afffliated Hospital of Nantong UniVersity Medical College","correspondingAuthor":false,"prefix":"","firstName":"Wu","middleName":"","lastName":"Xiao","suffix":""},{"id":436015032,"identity":"c45eba92-f5ef-4431-bc80-5d8dccb1046a","order_by":1,"name":"Sha JiangMing","email":"","orcid":"","institution":"the Afffliated Hospital of Nantong UniVersity 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country\u003c/p\u003e","description":"","filename":"OnlineFigure16.png","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/ebe916925dbb8fb0ae6c00f5.png"},{"id":79814844,"identity":"7e5e829e-ae28-4801-a731-8eba29c0ed4b","added_by":"auto","created_at":"2025-04-03 07:27:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1003637,"visible":true,"origin":"","legend":"\u003cp\u003eRespectively show the age-standardized point prevalence, Deaths rate, and disability-adjusted life-year rate of HHD in the Global Burden of Disease Study in country in 2021.\u003c/p\u003e\n\u003cp\u003eAge- standardised death rate of HHD per 100 000 population in 2021, by country\u003c/p\u003e","description":"","filename":"OnlineFigure23.png","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/3f6bbb9d7b5a88605eb9914a.png"},{"id":79815167,"identity":"549e6c19-42e7-4cef-b7e1-3404e83c6dc5","added_by":"auto","created_at":"2025-04-03 07:35:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1009914,"visible":true,"origin":"","legend":"\u003cp\u003eRespectively show the age-standardized point prevalence, Deaths rate, and disability-adjusted life-year rate of HHD in the Global Burden of Disease Study in country in 2021.\u003c/p\u003e\n\u003cp\u003eAge- standardised disability-adjusted life-year rate of HHD per 100 000 population in 2021, by country\u003c/p\u003e","description":"","filename":"OnlineFigure34.png","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/ef1cc1395356d60009439857.png"},{"id":79813671,"identity":"a13a08bd-7edd-4615-bc9b-1f37b7f393d7","added_by":"auto","created_at":"2025-04-03 07:11:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1034866,"visible":true,"origin":"","legend":"\u003cp\u003eAge-specific prevalence, deaths, and disability-adjusted life years (DALYs) of hypertensive heart disease by sex in 2021. Error bars represent the 95% uncertainty interval (UI) of the quantity.\u003c/p\u003e","description":"","filename":"OnlineFigure4.png","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/e847242fd8531787a9e7a9ff.png"},{"id":79813693,"identity":"6ce1f719-fbcc-4619-ba45-8b4a46c13e2a","added_by":"auto","created_at":"2025-04-03 07:11:39","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":566592,"visible":true,"origin":"","legend":"\u003cp\u003eTrends in age-standardized disability-adjusted life-year (DALY) rates due to hypertensive heart disease (HHD) for both sexes combined in 21 Global Burden of Disease Study (GBD) regions from 1990 to 2021, stratified by the Socio-demographic Index (SDI). Points from left to right for each region represent annual estimates from 1990 to 2021. The black solid line shows the expected values across the SDI spectrum.\u003c/p\u003e","description":"","filename":"OnlineFigure5.png","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/f60807a98cc57e24aeef88c2.png"},{"id":79813675,"identity":"03ed7749-e0a7-4653-b092-b1f5493f507f","added_by":"auto","created_at":"2025-04-03 07:11:38","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1011127,"visible":true,"origin":"","legend":"\u003cp\u003eAge-standardized DALY rates due to hypertensive heart disease by sex in 204 countries and territories in 2021, standardized by the Socio-demographic Index (SDI). The black solid line represents the expected values along the SDI spectrum.\u003c/p\u003e","description":"","filename":"OnlineFigure6.png","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/f2195971421b6d84307023ba.png"},{"id":79813689,"identity":"c9b9fbf0-52f0-4c4f-b877-b0f5e2aee595","added_by":"auto","created_at":"2025-04-03 07:11:38","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1083711,"visible":true,"origin":"","legend":"\u003cp\u003ePercentages of disability-adjusted life years (DALYs) due to risk factors for hypertensive heart disease (HHD) in different sexes in Global Burden of Disease Study (GBD) regions in 2021.（A, male. B, female.)\u003c/p\u003e","description":"","filename":"OnlineFigure7.png","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/3a58bef97ccdc70cdbf74320.png"},{"id":81569772,"identity":"3b60a04f-9478-4eac-abb1-12d761c5a9f1","added_by":"auto","created_at":"2025-04-28 16:11:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2144996,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/f9d8326e-9864-4572-adc0-c15dc5729bf6.pdf"},{"id":79813672,"identity":"b47d0a9c-b26f-4581-97ea-22cedb57eddf","added_by":"auto","created_at":"2025-04-03 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07:11:40","extension":"csv","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":44743032,"visible":true,"origin":"","legend":"","description":"","filename":"Global21regions204countries.csv","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/a905f133039cbafe1478f610.csv"},{"id":79813684,"identity":"1bb862c3-e00c-4602-99bb-731dd5460cdb","added_by":"auto","created_at":"2025-04-03 07:11:38","extension":"csv","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":1544295,"visible":true,"origin":"","legend":"","description":"","filename":"Global21regions204countrieschange.csv","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/b06ba8625ac57aad4164c16e.csv"},{"id":79813980,"identity":"d9dc41d9-e89a-4049-8e5d-e28fa56ededf","added_by":"auto","created_at":"2025-04-03 07:19:38","extension":"csv","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":4120,"visible":true,"origin":"","legend":"","description":"","filename":"orderglobal21regions204countries.csv","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/81e402da5607bfdad786a651.csv"},{"id":79814849,"identity":"2fa1ed1e-a2f4-4144-971e-d08a822b9424","added_by":"auto","created_at":"2025-04-03 07:27:39","extension":"csv","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":77177,"visible":true,"origin":"","legend":"","description":"","filename":"Global2021AgeandSex.csv","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/1a3a0406ccdc6fa58ea766e8.csv"},{"id":79813993,"identity":"a199093e-0fd6-4670-8286-9a5b09ac1cc9","added_by":"auto","created_at":"2025-04-03 07:19:39","extension":"csv","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":89570,"visible":true,"origin":"","legend":"","description":"","filename":"SDI19902021.csv","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/b22e65aa9c23e13058ab1004.csv"},{"id":79813680,"identity":"faeeaf7c-3c6a-4fea-bc24-46e79d47fbbe","added_by":"auto","created_at":"2025-04-03 07:11:38","extension":"csv","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":869326,"visible":true,"origin":"","legend":"","description":"","filename":"Riskfactor2021.csv","url":"https://assets-eu.researchsquare.com/files/rs-6008871/v1/f649da8f1767c8b94789c2be.csv"}],"financialInterests":"No competing interests reported.","formattedTitle":"Global Burden of Hypertensive Heart Disease and Attributable Risk Factors, 1990-2021: Insights from the Global Burden of Disease Study 2021","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHypertensive heart disease, a cardiac dysfunction resulting from hypertension, has gradually emerged as a major global health concern. Based on data from the World Health Organization (WHO), hypertension is a significant risk factor for cardiovascular diseases, impacting the health of billions of people globally. Current studies suggest that hypertensive heart disease not only causes alterations in cardiac structure and function but is also closely associated with complications like heart failure, atrial fibrillation, and coronary heart disease.\u003csup\u003e[1,2]\u003c/sup\u003eThere are significant differences in the epidemiological characteristics of hypertensive heart disease across different countries and regions, closely related to factors such as socioeconomic status, accessibility of medical resources, and public health policies. For example, studies have found that although high-income countries have a higher level of cardiovascular disease management, in low-income countries, due to a lack of medical resources, early screening and treatment for patients are often limited, leading to disease progression and an increased incidence of complications.\u003csup\u003e[3]\u003c/sup\u003e Additionally, women face a higher risk of cardiovascular complications after experiencing hypertension-related conditions such as pregnancy-induced hypertension.\u003csup\u003e[4]\u003c/sup\u003e This gender difference also varies across different regions, reflecting disparities in social culture and healthcare systems. \u003csup\u003e[5]\u003c/sup\u003eGlobally, research on hypertensive heart disease is gradually increasing, but there is still a lack of systematic epidemiological data to comprehensively assess the impact of this disease on public health. Particularly in low- and middle-income countries, data on the epidemiological characteristics, prevalence, and mortality of hypertensive heart disease are relatively scarce, necessitating in-depth exploration. \u003csup\u003e[6,7]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrevious analyses, including the GBD 2017 study, revealed regional variations in the burden of HHD, with low- and middle-income countries experiencing disproportionately greater impacts due to limited healthcare resources and poor blood pressure control.\u003csup\u003e[8]\u003c/sup\u003eHowever, a more recent analysis of the GBD 2021 dataset offers an updated and broader view of these trends. It incorporates data from the COVID-19 pandemic period, which might have intensified cardiovascular risk factors worldwide.This study aims to clarify global, regional, and national patterns in HHD prevalence, mortality, and DALYs, as well as key attributable risk factors.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Sources\u003c/h2\u003e \u003cp\u003eThe 2021 GBD study offers a meticulous evaluation of health impairments associated with 369 diseases, injuries, and impairments, along with 88 risk factors, encompassing 204 nations and territories, through the utilization of the most recent epidemiological data and enhanced standardized approaches. In this investigation, the estimates and their 95% uncertainty intervals (UI) for prevalence, deaths, and DALYs related to HHD were derived from the GBD 2021 data. \u003csup\u003e[9]\u003c/sup\u003e (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://ghdx.healthdata.org/gbd-2021\u003c/span\u003e\u003cspan address=\"http://ghdx.healthdata.org/gbd-2021\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) Additionally, the study employed the sociodemographic index (SDI), which is a metric that quantifies a region's sociodemographic development based on income, education, and fertility circumstances. \u003csup\u003e[10]\u003c/sup\u003e Furthermore, the University of Washington Institutional Review Board waived the necessity for informed consent to access the GBD data. \u003csup\u003e[11]\u003c/sup\u003e This research conformed to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). \u003csup\u003e[12]\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eKey Metrics\u003c/h3\u003e\n\u003cp\u003eHHD burden was quantified using prevalence, deaths, and DALY rates. DALYs were calculated as the sum of years of life lost (YLLs) due to premature mortality and years lived with disability (YLDs). Age-standardized rates were calculated using the global age structure to enable cross-country comparisons.\u003csup\u003e[13]\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eAttributable Risk Factors\u003c/h3\u003e\n\u003cp\u003eWe assessed the contributions of high systolic blood pressure, high BMI, dietary risks (e.g., high sodium and low fruit/vegetable intake), and alcohol use to HHD burden. Comparative risk assessment methodologies incorporated relative risks from meta-analyses and systematic reviews.\u003csup\u003e[14,15]\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll analyses were conducted using R (version 4.3.3). Uncertainty intervals (UIs) were computed based on 1,000 Monte Carlo simulations to account for data variability.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eTable 1 Prevalence,deaths, and disability-adjusted life years (DALYs) of hypertensive heart disease in 2021, and the percentage change in the standardized rate per 100,000 population (ASRs) in the Global Burden of Disease regions from 1990 to 2021.\u003c/p\u003e\n\u003ch4\u003eGlobal Trends\u003c/h4\u003e\n\u003cp\u003eIn 2021, the global prevalence of hypertensive heart disease (HHD) was approximated at 125.1 million instances (UI 117.3\u0026ndash;132.8), signifying an 18.2% augmentation in contrast to 1990. The age-standardized prevalence rate of HHD stood at 148.3 per 100,000 individuals, demonstrating a moderate escalation over three decades. Global age-standardized death and DALY rates for HHD exhibited remarkable enhancements, with declines of 22.0% and 25.8% respectively between 1990 and 2021. The mortality rate in 2021 was 16.3 per 100,000 population, and the DALY rate was 301.6 per 100,000 population. (Table 1)\u003c/p\u003e\n\u003cp\u003eTable 2\u0026nbsp; \u0026nbsp;Prevalent cases of hypertensive heart disease in 1990 and 2021 and the percentage change in the age-standardised rates (ASRs) per 100,000, by location\u003c/p\u003e\n\u003cp\u003eTable 3 \u0026nbsp;Deaths due to hypertensive heart disease in 1990 and 2021 and the percentage change in the age-standardised rates (ASRs) per 100,000, by location\u003c/p\u003e\n\u003cp\u003eTable 4 \u0026nbsp;DALYs due to hypertensive heart disease in 1990 and 2021 and the percentage change in the age-standardised rates (ASRs) per 100,000, by location\u003c/p\u003e\n\u003ch4\u003eRegional level\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eIn 2021, the age-standardized point prevalence of HHD (per 100,000 population) reached its peak in Eastern Sub-Saharan Africa (291.8), followed by Western Sub-Saharan Africa (266.3), and North Africa and the Middle East (243.3). In contrast, the lowest rates were observed in High-income Asia Pacific (57.6), Australia and New Zealand (52.4), and Eastern Europe (42.8) (Table 1). The age-standardized mortality rate of HHD (per 100,000 population) was highest in Central Sub-Saharan Africa (66.3), Southern Sub-Saharan Africa (47.4), and Eastern Sub-Saharan Africa (42.6) in 2021. The lowest rates were found in High-income Asia Pacific (3), Australia and New Zealand (2.4), and Eastern Europe (7.4) (Table 1). Similarly, the age-standardized DALY rate of HHD (per 100,000 population) was highest in Central Sub-Saharan Africa (1213.1), Southern Sub-Saharan Africa (889.1), and Eastern Sub-Saharan Africa (786.2) in 2021. The lowest rates were recorded in Australia and New Zealand (38.8), High-income Asia Pacific (47.1), and Western Europe (111.1) (Table 1). Figures S1-S3 display the age-standardized point prevalence, mortality rate, and DALY rate of HHD in the Global Burden of Disease Study for all regions in 2021, respectively.\u003c/p\u003e\n\u003cp\u003eFrom 1990 to 2021, the regions that witnessed the most significant increase in the age-standardized point prevalence of HHD were Australia and New Zealand (67%), High-income North America (64.2%), and Western Europe (53.3%). Conversely, the regions with the largest decrease were Central Latin America (-13%), East Asia (-10.9%), and Oceania (-7.6%) (Table 1). During the same period, the age-standardized mortality rate of HHD declined in most regions, with the most substantial decrease in High-income Asia Pacific (-71.8%), East Asia (-55.3%), and Central Latin America (-48.3%) (Table 1). From 1990 to 2021, the age-standardized DALY rate decreased in most regions, with the most significant reduction in High-income Asia Pacific (-70.4%), East Asia (-58.5%), and Central Latin America (-48.8%) (Table 1).\u003c/p\u003e\n\u003cp\u003eThe global number of prevalent cases of HHD rose from 125 million in 1990 to 148 million in 2021. In 1990, the highest number of prevalent cases of HHD was in South Asia, Central Asia, and China, and these regions continued to hold the top positions in 2021 (Table S1). The global number of deaths due to HHD decreased from 2.09 million in 1990 to 1.63 million in 2021. In 2021, the highest number of deaths was in Grenada, the Democratic Republic of the Congo, and Panama (Table S2). The number of DALYs due to HHD declined from 40.65 million in 1990 to 30.16 million in 2021. In 2021, the highest number of DALYs was in South Asia, China, and East Asia (Table S3).\u003c/p\u003e\n\u003ch4\u003eNational level\u003c/h4\u003e\n\u003cp\u003eIn 2021, the age-adjusted prevalence of HHD at the national level varied from 8.7 to 329.9 instances per 100,000 individuals. The highest age-adjusted prevalence rates of HHD were observed in the Cook Islands (317), the Bahamas (317.5), and Jordan (329.9), while the lowest estimates were noted in Belarus (8.7), Belgium (23), and Iceland (24.2) (Figure 1 and Table S1). The age-adjusted mortality rate of HHD at the national level in 2021 ranged from 1.1 to 103.4 cases per 100,000 people. The highest rates were recorded in Madagascar (77.6), Afghanistan (78.3), and Bulgaria (103.4), with the lowest rates in Belarus (1.1), Norway (2), and Belgium (21) (Figure 2 and Table S2). In 2021, the age-adjusted DALY rate of HHD at the national level ranged from 25 to 1739.3 cases per 100,000 people. The highest rates were seen in Madagascar (1509), Lesotho (1524.5), and Bulgaria (1739.3), while the lowest rates were observed in Belarus (25), Norway (27.4), and Belgium (29.8) (Figure 3 and Table S3).\u003c/p\u003e\n\u003ch4\u003eAge and Sex Patterns\u003c/h4\u003e\n\u003cp\u003eNumber of prevalent cases globally and prevalence of HHD per 100\u0026thinsp;000 population, by age and sex in 2021. Lines indicate prevalent case with 95% uncertainty intervals for men and women(Figure 4 A);Number of deaths cases globally and prevalence of HHD per 100\u0026thinsp;000 population, by age and sex in 2021. Lines indicate prevalent case with 95% uncertainty intervals for men and women(Figure 4 B);Number of DALYs cases globally and prevalence of HHD per 100\u0026thinsp;000 population, by age and sex in 2021. Lines indicate prevalent case with 95% uncertainty intervals for men and women(Figure 4 C)\u003c/p\u003e\n\u003cp\u003eGlobally, in 2021, the age-specific prevalence, mortality, and DALY rates of HHD escalated with age in both genders (Figure 4). The incidence of cases in men surpassed that in women prior to the age of 69, while the incidence of cases in women exceeded that in men after the age of 70. The peak was attained in men and women who were aged 70 to 74. The quantity of deaths and DALYs in men was greater than that in women before the age of 64, and the number of deaths and DALYs in women was higher than that in men after the age of 65. The peak mortality rate in men and women was reached at the age of 80-90, and the peak DALY rate was achieved at the age of 70-74.\u003c/p\u003e\n\u003cp\u003eAssociation with sociodemographic index\u003c/p\u003e\n\u003cp\u003eAge standardised disability adjusted life year (DALY) rates of HHD for the 21 Global Burden of Disease regions by sociodemographic index, 1990\u0026ndash;2021. Thirty-two points are plotted for each region and show the observed age standardised DALY rates from 1990 to 2021 for that region. Expected values, based on sociodemographic index and disease rates in all locations, are shown as a solid line. Regions above the solid line represent a higher than expected burden (eg, Central sub-saharan Africa) and regions below the line show a lower than expected burden (eg, Central Latin Americal)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGenerally, the age-standardized DALY rates for HHD in the 21 GBD regions decreased with increasing SDI (Figure 5). The age-standardized DALY rates in Central Sub-Saharan Africa, North Africa and Middle East, and Southern Sub-Saharan Africa were much higher than expected based on SDI for all years from 1990 to 2021. Despite the improvement in SDI over time, several regions, including Central Europe, Western Europe, and High-income North America, had an increase in age-standardized DALY rates from 1990 to 2021.\u003c/p\u003e\n\u003cp\u003eIt shows the relationship between age-standardized DALY rates and SDI at the country level in 204 countries and territories worldwide in 2021. Similar to regional trends, age-standardized DALY rates at the country level showed a decreasing trend with increasing SDI. Age-standardized DALY rates in Afghanistan, Madagascar, Bulgaria, Panama, and many other countries were much higher than expected based on SDI.\u003c/p\u003e\n\u003cp\u003eThe disability-adjusted life years (DALYs) caused by hypertensive heart disease (HHD) due to individual risk factors are approximately the same in different genders. The top 8 risk diets for hypertensive heart disease (HHD) are high blood pressure, high metabolic score, high BMI, high sodium diet, alcohol consumption,Low fruit intake, Low vegetable intake, and behavioral risks.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMajor Trends in Global Disease Burden\u003c/h2\u003e \u003cp\u003eGlobally, sub-Saharan Africa and Southeast Asia face the highest burden of disease. The high disability-adjusted life years (DALYs) and mortality rates in both regions suggest that infectious diseases, malnutrition, and poverty pose a long-term threat to public health \u003csup\u003e[16\u0026ndash;18]\u003c/sup\u003e. Lack of nutrition is particularly acute in sub-Saharan Africa, resulting in a significant number of deaths and disease, particularly in low-and middle-income countries, \u003csup\u003e[16]\u003c/sup\u003e. Moreover, with the acceleration of urbanization and population growth, the spread of infectious diseases and the aggravation of malnutrition put the public health resources in these areas under great pressure\u003csup\u003e[17]\u003c/sup\u003e。In comparing health status in low-and middle-income countries, high-income countries (e. g., Nordic, Australia and Canada) significantly reduced disease burden through an efficient healthcare system and successful public health policies. Public health spending and health systems responsiveness in these countries have played an important role in improving health status among low-income populations\u003csup\u003e[19]\u003c/sup\u003e. For example, there are differences in income in Canada and Australia, but public health policies in both countries partly alleviate these inequalities\u003csup\u003e[20]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThese regional differences reveal a trend of increasing importance for chronic diseases. In Central America and the Caribbean, the high incidence of chronic diseases (e. g., cardiovascular disease, diabetes) has a significant impact on healthspan, although the mortality rate is lower \u003csup\u003e[21,22]\u003c/sup\u003e. These chronic diseases not only affect the quality of life of individuals, but also cause significant stress on the public health system and the economy\u003csup\u003e[23,24]\u003c/sup\u003e .\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAge and Gender Disparities\u003c/h2\u003e \u003cp\u003eAge and sex have a profound influence on the distribution of disease burden. The results of 2021 have shown that the prevalence of disease and disability-adjusted life years (DALYs) have increased significantly with increasing age, with the burden of chronic disease becoming the main problem \u003csup\u003e[25,26]\u003c/sup\u003e.In China, the economic burden of chronic diseases has also attracted widespread attention, especially in the elderly group, where household economic pressure has significantly increased in\u003csup\u003e[27]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTherefore, health policies and interventions targeting older populations need to focus more on the prevention and management of chronic diseases to reduce the disease burden and healthcare costs in the future \u003csup\u003e[26,28]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe health burden of men was more pronounced at younger ages, mainly due to high-risk behaviors (e. g., smoking, drinking) and occupational exposure. This difference was particularly evident in disability-adjusted life years (DALYs) and mortality \u003csup\u003e[29,30]\u003c/sup\u003e. The generalizability of smoking and alcohol consumption coupled with high intensity occupational requirements in young men leads to higher health risk and greater burden of disease\u003csup\u003e[31]\u003c/sup\u003e. In older age, the health burden of women gradually approaches that of men, and chronic disease management becomes the key to health strategies in this stage. Research indicates that as women age, they experience an increasing prevalence of chronic conditions, which significantly impacts their overall health and quality of life \u003csup\u003e[32]\u003c/sup\u003e. This trend necessitates a focused approach to managing chronic diseases, particularly as women often face unique challenges related to their health literacy and access to care\u003csup\u003e[33]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eThe Relationship Between SDI and Disease Burden\u003c/h2\u003e \u003cp\u003eIn global health, the negative correlation between the level of socio-economic development (SDI) and disease burden further emphasizes the importance of economic development. Low SDI regions (e. g., sub-Saharan Africa) face high disability-adjusted life years (DALYs) burden due to infectious diseases and neonatal health problems \u003csup\u003e[34,35]\u003c/sup\u003e. However, the health challenges of some medium socio-economic development index (SDI) countries (such as Eastern Europe) have exceeded expectations, which is closely related to the health problems caused by the socioeconomic transition. This suggests that simply increasing SDI alone is not sufficient to fully address the disease burden. Studies have shown that economic development and medical expenditure are important factors in achieving high life expectancy, but the spread of modern diseases (e. g., obesity and diabetes) has a significant negative impact on life expectancy \u003csup\u003e[36]\u003c/sup\u003e. Therefore, region-specific health interventions and policies should consider these complex socioeconomic factors to effectively respond to the disease burden of \u003csup\u003e[37]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eKey Risk Factors and Regional Characteristics\u003c/h2\u003e \u003cp\u003eBehavioral and metabolic risk factors play a significant role in global disease burden, with notable regional differences:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eHigh-income countries\u003c/b\u003e: Behavioral risks (e.g., high-sodium diet, alcohol use) and metabolic risks (e.g., hypertension, high BMI) are major contributors, with chronic diseases such as cardiovascular conditions being dominant\u003csup\u003e[38\u0026ndash;40]\u003c/sup\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSub-Saharan Africa\u003c/b\u003e: Despite lower metabolic risks, infectious diseases and malnutrition result in a significant health burden\u003csup\u003e[41,42]\u003c/sup\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSouth Asia and Southeast Asia\u003c/b\u003e: Low fruit and vegetable intake are prominent behavioral risks, while hypertension and high BMI are emerging as critical health challenges\u003csup\u003e[43,44]\u003c/sup\u003e.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCentral Asia and Eastern Europe\u003c/b\u003e: Alcohol consumption and high-sodium diets are significant behavioral risks, while metabolic risks like hypertension and obesity directly contribute to high DALYs\u003csup\u003e[45,46]\u003c/sup\u003e. Studies show that levels of alcohol-related health hazards are higher in Eastern Europe than in Western Europe, and although historical and cultural factors have profound effects on drinking patterns, effective policy responses have been effective in some countries\u003csup\u003e[45]\u003c/sup\u003e .\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eGlobally, metabolic risks such as hypertension and high BMI are becoming increasingly prominent with economic development and lifestyle changes. Behavioral risks, however, reflect regional socioeconomic and cultural differences. These findings highlight the importance of tailored health interventions, such as promoting dietary and lifestyle improvements in high-income countries and strengthening infectious disease prevention and nutritional support in low-income regions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThe analysis is constrained by variations in data quality across regions, which may lead to underestimation or overestimation of the disease burden in some areas. Furthermore, the growing prevalence of metabolic disorders (e.g., diabetes, chronic kidney disease) complicates the current health landscape. Future research should integrate these emerging risks to provide a more comprehensive assessment.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe significant regional, age, and gender disparities in global disease burden underscore the need for equity and precision in health strategies. Strengthening basic healthcare services and public health investments in low-SDI regions, improving chronic disease management in middle-SDI regions, and optimizing healthy lifestyles in high-SDI regions can effectively reduce the global disease burden.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e : not applicable.\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Jiangsu Provincial Health Commission, Y12023027\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ethe University of Washington Institutional Review Board waived the requirement for informed consent to access the GBD data. This research adhered to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests :\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used for the analyses in the study are publicly available at https://ghdx.healthdata.org/gbd-results-tool.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMasenga SK, Kirabo A. Hypertensive heart disease: risk factors, complications and mechanisms. Front Cardiovasc Med. 2023;10:1205475. Published 2023 Jun 5. doi:10.3389/fcvm.2023.1205475\u003c/li\u003e\n \u003cli\u003eWestaby JD, Miles C, Chis Ster I, et al. Characterisation of hypertensive heart disease: pathological insights from a sudden cardiac death cohort to inform clinical practice. 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J Hum Hypertens. 2022;36(5):437-444. doi:10.1038/s41371-020-00480-6\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6008871/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6008871/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHypertensive heart disease (HHD) significantly contributes to global morbidity and mortality, worsened by rising hypertension rates.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aims to assess the burden of HHD from 1990 to 2021, analyzing prevalence, mortality, and disability-adjusted life years (DALYs) stratified by age, sex, and Sociodemographic Index (SDI). Utilizing data from the Global Burden of Disease 2021 project across 204 countries and 21 regions, the study calculated age-standardized rates and evaluated risk factors for prevention priorities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn 2021, there were 12.5\u0026nbsp;million HHD cases globally, resulting in 1.332\u0026nbsp;million deaths and 25.4622\u0026nbsp;million DALYs. Age-standardized rates were 148.3 for prevalence, 16.3 for deaths, and 301.6 for DALYs per 100,000 people, reflecting increases of 18.2% for prevalence but decreases for deaths (-22%) and DALYs (-25.8%) since 1990. Eastern Sub-Saharan Africa recorded the highest prevalence (291.8), while Bulgaria had the highest mortality (103.4) and DALY rates (1739.3).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAge-specific trends showed that prevalence, deaths, and DALYs increased with age across genders, and at regional levels, DALYs decreased with higher SDI. Major contributing factors included high systolic blood pressure, metabolic risks, high body-mass index, unhealthy diet, alcohol use, and low fruit and vegetable intake.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite advances in management, HHD remains a global health concern, especially in low-SDI areas. Efforts focused on modifiable risks, like hypertension control and dietary improvements, are essential to mitigate the burden of HHD.\u003c/p\u003e","manuscriptTitle":"Global Burden of Hypertensive Heart Disease and Attributable Risk Factors, 1990-2021: Insights from the Global Burden of Disease Study 2021","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 07:11:32","doi":"10.21203/rs.3.rs-6008871/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-07T22:39:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-06T12:52:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-05T08:18:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181096403966484072002987195974628270879","date":"2025-03-30T21:53:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254290152347503070314260222703166214404","date":"2025-03-30T06:41:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39192421324293194307412483323153458931","date":"2025-03-29T05:56:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-28T16:18:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-28T16:00:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-25T10:08:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-25T03:00:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-03-25T02:59:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"997f3e1e-b880-4845-b221-c2fbb2f31bc7","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46420619,"name":"Biological sciences/Computational biology and bioinformatics"},{"id":46420621,"name":"Earth and environmental sciences/Biogeochemistry"},{"id":46420623,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-04-28T16:04:13+00:00","versionOfRecord":{"articleIdentity":"rs-6008871","link":"https://doi.org/10.1038/s41598-025-99358-1","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-04-26 15:58:22","publishedOnDateReadable":"April 26th, 2025"},"versionCreatedAt":"2025-04-03 07:11:32","video":"","vorDoi":"10.1038/s41598-025-99358-1","vorDoiUrl":"https://doi.org/10.1038/s41598-025-99358-1","workflowStages":[]},"version":"v1","identity":"rs-6008871","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6008871","identity":"rs-6008871","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}