European Journal of Preventive Cardiology (2022) 29, 420–431 FULL RESEARCH PAPER

https://doi.org/10.1093/eurjpc/zwab213 Cardiovascular Disease

Burden of ischemic heart disease and its

attributable risk factors in 204 countries and
territories, 1990–2019
Saeid Safiri1,2,3, Nahid Karamzad4, Kuljit Singh5,6,7, Kristin Carson-Chahhoud8,9,

Downloaded from https://academic.oup.com/eurjpc/article/29/2/420/6469679 by guest on 17 April 2022

Cobi Adams10, Seyed Aria Nejadghaderi2,11, Amir Almasi-Hashiani 12,
Mark J.M. Sullman13,14, Mohammad Ali Mansournia15, Nicola Luigi Bragazzi 16,
Jay S. Kaufman 17, Gary S. Collins 18,19, and Ali-Asghar Kolahi20*
1
Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran; 2Social Determinants of Health Research Center,
Department of Community Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran; 3Cardiovascular Research Center, Tabriz University of Medical
Sciences, Tabriz, Iran; 4Nutrition Research Center, Department of Biochemistry and Diet Therapy, School of Nutrition and Food Sciences, Tabriz University of Medical Sciences,
Tabriz, Iran; 5Department of Cardiology, Gold Coast University Hospital, Gold Coast, QLD, Australia; 6Department of Medicine, Griffith University, Southport, QLD, Australia;
7
Department of Medicine, Bond University, Robina, QLD, Australia; 8Australian Centre for Precision Health, University of South Australia, Adelaide, SA, Australia; 9School of
Medicine, University of Adelaide, Adelaide, SA, Australia; 10Department of Medicine, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia; 11Systematic Review and
Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran; 12Department of Epidemiology, School of Health, Arak
University of Medical Sciences, Arak, Iran; 13Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus; 14Department of Social Sciences, University of
Nicosia, Nicosia, Cyprus; 15Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; 16Centre for Disease
Modelling, York University, Toronto, ON, Canada; 17Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC,
Canada; 18Centre for Statistics in Medicine, NDORMS, Botnar Research Centre, University of Oxford, Oxford, UK; 19NIHR Oxford Biomedical Research Centre, Oxford
University Hospitals NHS Foundation Trust, Oxford, UK; and 20Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Received 26 September 2021; revised 28 November 2021; editorial decision 30 November 2021; accepted 5 December 2021; online publish-ahead-of-print 18 December 2021

Aims To report the prevalence, deaths, and disability-adjusted life years (DALYs) associated with ischemic heart disease
(IHD) and its attributable risk factors in 204 countries and territories from 1990 to 2019, by age, sex, and socio-
demographic index (SDI).
...................................................................................................................................................................................................
Methods Ischemic heart disease was defined as acute myocardial infarction (MI) and chronic IHD (angina; asymptomatic IHD
and results following MI). Cause of death ensemble modelling was used to produce fatality estimates. The prevalence of the
non-fatal sequalae of IHD was estimated using DisMod MR 2.1. All estimates were presented as counts and age-
standardized rates per 100 000 population. In 2019, IHD accounted for 197.2 million (177.7–219.5) prevalent cases,
9.1 million (8.4–9.7) deaths, and 182.0 million (170.2–193.5) DALYs worldwide. There were decreases in the global
age-standardized prevalence rates of IHD [ 4.6% ( 5.7, 3.6)], deaths [ 30.8% ( 34.8, 27.2)], and DALYs
[ 28.6% ( 33.3, 24.2)] from 1990 to 2019. In 2019, the global prevalence and death rates of IHD were higher
among males across all age groups, while the death rate peaked in the oldest group for both sexes. A negative as-
sociation was found between the age-standardized DALY rates and SDI. Globally, high systolic blood pressure
(54.6%), high low-density lipoprotein cholesterol (46.6%), and smoking (23.9%) were the three largest contributors
to the DALYs attributable to IHD.
...................................................................................................................................................................................................
Conclusion Although the global age-standardized prevalence, death, and DALY rates all decreased. Prevention and control pro-
grammes should be implemented to reduce population exposure to risk factors, reduce the risk of IHD in high-risk
populations, and provide appropriate care for communities.
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Keywords Ischemic heart disease • Epidemiology • Global burden of disease • Risk factor

* Corresponding author. Tel: 0098-2122220980, Email: a.kolahi@sbmu.ac.ir

C The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.
Published on behalf of the European Society of Cardiology. All rights reserved. V
Burden of IHD, 1990–2019
..
Introduction
Among non-communicable diseases (NCDs), cardiovascular diseases
(CVDs) are the single largest contributor to the global burden of dis-
ease and are recognized as the leading cause of death globally.1 In
2019, there were 56.5 million deaths globally, with 32.9% of them
(18.6 million deaths) being due to CVDs.1,2 Measuring CVDs is also
important in meeting organization commitments, such as the United
Nation’s sustainable development goals (SDGs), which were intro-
duced in 2015. One of the SDGs is to reduce the premature mortal-
ity rate from NCDs by one-third, which could be partially achieved
by decreasing CVDs, and in particular, ischemic heart disease
(IHD).3,4 Therefore, monitoring the burden of IHD is critically
important.
A stepwise approach has been presented for countries involving
monitoring the level and trends associated with the diseases, and
therefore, accurate surveillance is a key factor, for which systematic,
comprehensive, and up-to-date data is required.3 To the best of our
knowledge, no recent global study has comprehensively reported the
burden of IHD. A small number of studies have estimated the global
incidence and mortality rates for all CVDs in 2013,5 2015,6 and
2019,2 and the mortality rate of IHD in 2014,7 but no study has
focused on comprehensively understanding the global burden of
IHD. Hence, this study aimed to report the global, regional, and na-
tional prevalence, deaths, and disability-adjusted life years (DALYs)
due to IHD, and its attributable risk factors, for 204 countries and ter-
ritories from 1990 to 2019, by age, sex, and socio-demographic index
(SDI).
Methods
Overview
In GBD 2019, 369 diseases and injuries and 87 risk factors were systemat-
ically analysed in 204 countries and territories, 7 super-regions, and 21
regions from 1990 to 2019. The general methodology of GBD 2019, and
the main changes from previous years, have been described in detail else-
where.1,8,9 Additional information on the fatal and non-fatal estimates can
be found on the Global Health Data Exchange and are publicly available
on the Institute for Health Metrics and Evaluation website [Available
from: http://ghdx.healthdata.org/gbd-results-tool].
Case definition
Ischemic heart disease included two categories, which were acute myo-
cardial infarction (MI) and chronic IHD (angina and asymptomatic IHD
following MI). Myocardial infarction was defined as definite and possible
MI, as described by the third universal definition of MI.10 Angina was
defined as clinically diagnosed as stable exertional angina pectoris or def-
inite angina pectoris according to the Rose Angina Questionnaire (RAQ),
physician diagnosis, or taking nitrate medication for the relief of chest
pain. Asymptomatic IHD, following MI, was defined as survival for 28 days
following an MI incident. The GBD study does not use estimates based
on electrocardiogram evidence of prior MI, due to its limited specificity
and sensitivity.1
Fatal estimation
Cause of death ensemble modelling (CODEm) was used to model deaths
from IHD, with the covariates used in the modelling being presented in
Supplementary material online, Table S1. Vital registration and verbal
421
.. autopsy data were used to model IHD. Verbal autopsy data were not
.. included in our models in countries and subnational locations where
.. high-quality vital registration data was available. Also excluded were non-
..
.. representative subnational verbal autopsy data points, ICD8 and ICD9,
.. basic tabulation list (BTL) data points that were inconsistent with the rest
..
.. of the data and created implausible time trends, and data from a number
.. of Indian states, which were identified by experts as poor-quality. The
..
.. flowchart of the estimation process is presented elsewhere.1
..
..
.. Non-fatal estimation
.. A number of different data sources were used to generate estimates for
.. MI, asymptomatic IHD following MI, and angina. The data sources used
..
.. for each country and GBD region, and more details about the estimation
.. process are available in the capstone paper.1 The disease modelling of MI,
..
Downloaded from https://academic.oup.com/eurjpc/article/29/2/420/6469679 by guest on 17 April 2022
.. asymptomatic IHD, and angina was conducted using DisMod MR 2.1,
.. which provided estimates for their prevalence and incidence.
..
..
.. Myocardial infarction
..
.. Custom cause-specific mortality estimates were calculated using cause of
.. death data, prior to garbage code redistribution. This process generated
..
.. age–sex–country-specific proportions of IHD deaths that were due to MI
.. (acute IHD) vs. those due to other causes of IHD (chronic IHD).
.. Estimates for all locations were then generated using a DisMod
..
.. proportion-only model. As there was a high degree of variability in the
.. pre-redistribution coding practices for each location, the global age-, sex-,
..
.. and year-specific proportions of acute deaths were used in all following
.. calculations. The global proportions were multiplied by the final GBD
..
.. estimates of deaths due to IHD in order to generate cause-specific mor-
.. tality estimates, even though GBD only reports deaths for all IHD com-
.. bined. These data, along with the incidence and excess mortality data,
..
.. were used in the DisMod model to estimate the prevalence and incidence
.. of MI from IHD. These were then split into the prevalence and incidence
..
.. estimates for Days 1 and 2 and Days 3–28 post-event, and disability
.. weights (DWs) were assigned to each. Further detailed information is
.. available in the capstone paper.1
..
..
..
.. Asymptomatic ischemic heart disease
.. Excess mortality estimates from the MI model were used to generate
.. data about the incidence of survival 28 days after the MI. These data, along
..
.. with the estimates of CSMR due to chronic IHD and excess mortality
.. data in a DisMod model, were used to estimate the prevalence of IHD
..
.. following MI. This estimates included subjects with angina and heart fail-
.. ure. In order to avoid double counting, based on evidence from the litera-
..
.. ture, a proportion of the cases were removed. This process generated
.. estimates of the prevalence of asymptomatic IHD following MI. The cova-
.. riates included in the models and more detailed information have been
..
.. presented elsewhere.1
..
..
.. Angina
.. The prevalence data from the literature and American claims databases,
..
.. as well as the data on mortality risk, were used to estimate the prevalence
.. and incidence of angina in all locations. The proportions of mild, moder-
..
.. ate, and severe angina were estimated using the standard GBD 2019 ap-
.. proach for severity splitting. The covariates included in the model and
..
.. more detailed information have been previously reported.1
..
..
.. Severity and years lived with disability
.. The diseases coded I20–I21.6, I21.9–I25.9, and Z82.4–Z82.49 in the
.. International Classification of Diseases (ICD) version 10 were considered
..
. to be IHD. Acute MI was split into two severity levels, according to the
422
length of time since the event: Days 1 and 2 and Days 3–28. Disability
weights were estimated using the standard GBD 2019 approach.
Asymptomatic IHD following MI was assigned to the asymptomatic se-
verity level and no DWs were provided. Angina was split into asymptom-
atic, mild, moderate, and severe using information from the US Medical
Expenditure Panel Survey (MEPS).1 Disability weights were generated for
these four groups using the standard approach for GBD 2019
(Supplementary material online, Table S2). The prevalence of each group
was multiplied by their severity-specific DWs, in order to calculate the
years lived with disability (YLDs).
Compilation of results
The years of life lost (YLLs) were calculated by multiplying the number of
deaths in each age group by the remaining life expectancy in that age
group using the GBD standard life table. Disability-adjusted life years
were calculated as the sum of YLLs and YLDs. Uncertainty was propa-
gated by sampling 1000 draws at each computational step, which allowed
us to combine uncertainty from multiple sources, including input data,
corrections of measurement error, and estimates of residual non-
sampling error. Uncertainty intervals (UIs) were defined as the 25th and
975th values of the ordered draws.
Risk factors
The percentage of DALYs due to the following risk factors for IHD were
calculated: high systolic blood pressure (SBP), high low-density lipoprotein
(LDL) cholesterol, smoking, high fasting plasma glucose (FPG), high body
mass index (BMI), ambient particulate matter, kidney dysfunction, house-
hold air pollution, low temperature, second-hand smoke, lead exposure,
low physical activity, high temperature, diets low in whole grains, diets low
in legumes, diets high in sodium, diets high in trans fatty acids, diets low in
nuts and seeds, diets low in fruits, diets low in vegetables, diets low in fibre,
diets low in polyunsaturated fats, diets high in red meat, diets low in sea-
food omega-3 fatty acids, diets high in processed meat, and diets high in
sugar-sweetened beverages. Details on the definitions of these risk factors
and their relative risk for IHD are provided elsewhere.8
Role of the funding source
The funder of the study had no role in the design of the study, data collec-
tion, data analysis, data interpretation, or writing of the report. The
Shahid Beheshti University of Medical Sciences funded the present report
(grant number: 26866).
Results
Global level
There were 197.2 million (95% UI: 177.7 to 219.5) prevalent cases of
IHD in 2019, with an age-standardized rate of 2421.0 (95% UI: 2180.5
to 2692.6), which was 4.6% (95% UI: 5.7 to 3.6) lower than that
found in 1990. In 2019, 9.1 million (95% UI: 8.4 to 9.7) deaths
occurred due to IHD, with an age-standardized death rate of 118.0
(95% UI: 107.8 to 125.9), which decreased by 30.8% (95% UI: 34.8
to 27.2) across the measurement period. Ischemic heart disease
accounted for 182.0 million (95% UI: 170.2 to 193.5) DALYs in 2019,
with an age-standardized rate of 2243.5 (95% UI: 2098.7 to 2385.0).
There was a 28.6% (95% UI: 33.3 to 24.2) decrease in DALYs
across the reporting period (Table 1).
S. Safiri et al.
.. Regional level
..
.. North Africa and the Middle East [4911.1 (95% UI: 4552.7 to
..
.. 5295.1)], Central Asia [4131.8 (95% UI: 3827.6 to 4475.2)], and
.. Eastern Europe [3684.8 (95% UI: 3318.2 to 4094.9)] had the highest
..
.. age-standardized prevalence of IHD in 2019. In contrast, the lowest
.. were found in high-income Asia-Pacific region [1059.7 (95% UI: 962.5
..
.. to 1162.7)], Andean Latin America [1150.6 (95% UI: 994.7 to
.. 1342.6)], and Southern Latin America [1152.3 (95% UI: 1059.8 to
..
.. 1249.6)] (Table 1). The 2019 sex-specific estimates for the age-stand-
.. ardized prevalence of IHD at the regional-level are presented in
..
.. Supplementary material online, Figure S1.
..
.. In 2019, Central Asia [360.0 (95% UI: 330.9 to 390.2)], Eastern
.. Europe [284.6 (95% UI: 253.6 to 310.1)], and North Africa and the
..
Downloaded from https://academic.oup.com/eurjpc/article/29/2/420/6469679 by guest on 17 April 2022
.. Middle East [219.0 (95% UI: 194.2 to 246.8)] had the highest age-
.. standardized death rates due to IHD. In contrast, the high-income
..
.. Asia-Pacific region [30.5 (95% UI: 25.7 to 33.3)], Australasia [59.0
... (95% UI: 51.3 to 63.4)], and Western Europe [60.7 (95% UI: 54.2 to
.. 64.9)] had the lowest age-standardized death rates due to IHD (Table
..
.. 1). The sex-specific estimates of the age-standardized death rates of
.. IHD at the regional-level are shown in Supplementary material on-
..
.. line, Figure S2.
.. Central Asia [6272.8 (95% UI: 5736.1 to 6861.6)], Eastern Europe
..
.. [5016.4 (95% UI: 4514.7 to 5525.9)], and Oceania [4529.0 (95% UI:
..
.. 3654.6 to 5673.9)] had the highest age-standardized DALY rates due
.. to IHD in 2019. In contrast, the high-income Asia-Pacific region
..
.. [524.3 (95% UI: 475.4 to 558.0)], Australasia [926.5 (95% UI: 857.6 to
.. 976.4)], and Western Europe [975.4 (95% UI: 912.9 to 1022.3)] had
..
.. the lowest age-standardized DALY rates for that same year (Table 1).
.. The 2019 sex-specific estimates for the age-standardized DALY rates
..
.. of IHD at the regional-level can be found in Supplementary material
.. online, Figure S3.
..
.. The largest increases in the age-standardized prevalence rates, be-
.. tween 1990 and 2019, were seen in Western Sub-Saharan Africa
..
.. [10.2% (95% UI: 9.0 to 11.4)], East Asia [6.0% (95% UI: 4.4 to 7.7)],
.. and Eastern Sub-Saharan Africa [5.6% (95% UI: 4.5 to 6.7)]. In con-
..
.. trast, the largest decreases were seen in high-income North America
..
.. [ 36.2% (95% UI: 38.3 to 33.9)], Central Europe [ 17.9% (95%
.. UI: 19.0 to 16.3)], and Western Europe [ 17.3% (95% UI: 21.1
..
.. to 13.3)] (Table 1). At the regional-level, the sex-specific estimates
.. for the percentage change in the age-standardized prevalence of IHD,
..
.. from 1990 to 2019, can be found in Supplementary material online,
.. Figure S4.
..
.. The age-standardized death rate of IHD generally decreased from
.. 1990 to 2019 in all GBD regions, except for Central Asia which saw
..
.. an 11.7% (95% UI: 3.8 to 22.0) increase. The largest decreases, across
.. this period, were seen in Australasia [ 67.0% (95% UI: 68.9 to
..
.. 65.4)], High-income Asia-Pacific [ 64.4% (95% UI: 67.3 to
..
.. 62.4)], and Western Europe [ 61.2% (95% UI: 62.9 to 59.1)]
.. (Table 1). At the regional-level, the sex-specific estimates for the per-
..
.. centage change in the age-standardized death rates from IHD, during
.. the period 1990–2019, can be found in Supplementary material on-
..
.. line, Figure S5.
.. There were no increases in the age-standardized DALY rate for
..
.. IHD across the GBD regions from 1990 to 2019. Australasia
.. [ 70.2% (95% UI: 71.5 to 69.1)], Western Europe [ 63.8% (95%
..
. UI: 65.1 to 62.3)], and high-income Asia-Pacific [ 63.7% (95% UI:
Table 1 Prevalent cases, deaths, and DALYs for ischemic heart disease in 2019 for both sexes and percentage change of age-standardized rates (ASRs) per 100 000
by GBD regions during 1990–2019

Prevalence (95% UI) Deaths (95% UI) DALYs (95% UI)

........................................................................................... .................................................................................... ...........................................................................................
No (95% UI) ASRs per Percentage No (95% UI) ASRs per Percentage No (95% UI) ASRs per Percentage
100 000 (95% change in ASRs 100 000 (95% change in ASRs 100 000 (95% change in ASRs
UI) between 1990 UI) between 1990 UI) between 1990
and 2019 and 2019 and 2019
Burden of IHD, 1990–2019

..........................................................................................................................................................................................................................................................................................................
Global 197 219 450 (177 688 201, 2421 (2180.5, 4.6 ( 5.7, 3.6) 9 137 791 (8 395 682, 118 (107.8, 125.9) 30.8 ( 34.8, 182 030 144 (170 206 778, 2243.5 (2098.7, 28.6 ( 33.3,
219 501 074) 2692.6) 9 743 550) 27.2) 193 504 630) 2385) 24.2)
High-income Asia 4 644 221 (4 189 900, 1059.7 (962.5, 15.9 ( 17.8, 172 964 (139 728, 30.5 (25.7, 33.3) 64.4 ( 67.3, 2 355 723 (2 048 498, 524.3 (475.4, 558) 63.7 ( 65.4,
Pacific 5 121 731) 1162.7) 14) 191 814) 62.4) 2 536 037) 61.9)
High-income 9 984 025 (9 019 560, 1625.9 (1480.2, 36.2 ( 38.3, 606 489 (539 683, 88.1 (79.6, 93.4) 51 ( 52.5, 9 684 545 (9 060 635, 1569.1 (1482.2, 51.5 ( 52.7,
North America 10 961 606) 1776.6) 33.9) 647 145) 48.8) 10 169 474) 1646.5) 49.7)
Western Europe 15 757 318 (14 313 581, 1810.7 (1650.2, 17.3 ( 21.1, 666 760 (586 750, 60.7 (54.2, 64.9) 61.2 ( 62.9, 9 125 380 (8 365 311, 975.4 (912.9, 63.8 ( 65.1,
17 253 097) 1975.6) 13.3) 718 140) 59.1) 9 645 800) 1022.3) 62.3)
Australasia 1 387 757 (1 288 164, 2836.8 (2639.8, 13 ( 15.8, 9.4) 33 125 (28 421, 59 (51.3, 63.4) 67 ( 68.9, 465 283 (425 548, 926.5 (857.6, 70.2 ( 71.5,
1 493 861) 3044.5) 35 760) 65.4) 492 760) 976.4) 69.1)
Andean Latin 635 050 (549 392, 1150.6 (994.7, 0.7 ( 1.3, 2.7) 34 446 (28 404, 64.5 (53, 76.5) 41.3 ( 52.3, 642 173 (533 705, 1148.6 (953.9, 42.9 ( 54,
America 740 820) 1342.6) 40 971) 28.5) 771 321) 1378.3) 29.8)
Tropical Latin 4 100 838 (3 532 588, 1710.2 (1467.8, 1 ( 2.4, 0.6) 175 999 (160 324, 75.2 (68.2, 79.4) 51.9 ( 54.2, 3 819 129 (3 598 322, 1567.5 (1474.1, 49.3 ( 51.6,
America 4 783 990) 1995.8) 185 401) 49.7) 3 996 709) 1642) 47)
Central Latin 4 538 981 (4 056 906, 1957 (1743.1, 5.2 ( 6, 4.3) 219 022 (189 141, 97.4 (83.8, 111.3) 25.7 ( 33.9, 4 140 250 (3 621 097, 1763.3 (1540.9, 26.7 ( 35.7,
America 5 105 335) 2196.5) 250 607) 16) 4 779 531) 2032.1) 16)
Southern Latin 964 295 (885 975, 1152.3 (1059.8, 16.3 ( 18.9, 61 452 (55 939, 72 (65.8, 76.7) 55.3 ( 57.3, 1 059 333 (993 997, 1277.9 (1200.2, 54.5 ( 56.6,
America 1 045 361) 1249.6) 12.3) 65 419) 53.1) 1 113 502) 1342.9) 52.3)
Caribbean 1 683 036 (1 541 981, 3256.1 (2983.9, 2.4 ( 3.7, 1.1) 63 535 (55 083, 122.1 (106, 139.7) 34 ( 41.9, 1 245 510 (1 074 980, 2408.8 (2077.2, 30.9 ( 40.3,
1 837 628) 3554.7) 72 649) 25.8) 1 435 112) 2777.6) 21.1)
Central Europe 6 005 621 (5 299 667, 2785.6 (2475.4, 17.9 ( 19, 354 125 (308 352, 159.8 (139, 178.4) 46.8 ( 52.4, 5 471 195 (4 817 040, 2567.6 (2257.2, 51.1 ( 56.9,
6 810 132) 3150.8) 16.3) 395 305) 41.4) 6 135 890) 2885.6) 45.5)
Eastern Europe 12 847 142 (11 531 742, 3684.8 (3318.2, 2.6 (1.6, 3.6) 986 560 (879 471, 284.6 (253.6, 12.9 ( 19.5, 17 082 365 (15 385 816, 5016.4 (4514.7, 11.5 ( 19.3,
14 334 753) 4094.9) 1 075 171) 310.1) 6.1) 18 795 519) 5525.9) 3.2)
Central Asia 2 763 285 (2 544 108, 4131.8 (3827.6, 2.3 (1, 3.7) 200 135 (183 535, 360 (330.9, 390.2) 11.7 (3.8, 20.2) 4 241 258 (3 857 028, 6272.8 (5736.1, 6.3 ( 2.4, 16.2)
3 006 299) 4475.2) 218 271) 4 674 597) 6861.6)
North Africa and 1 9979 927 (18 501 725, 4911.1 (4552.7, 3.5 ( 4.5, 2.2) 799 484 (706 349, 219 (194.2, 246.8) 29.2 ( 36.9, 17 994 822 (15 580 582, 4158.9 (3650.7, 33.3 ( 41.4,
Middle East 21 563 635) 5295.1) 909 787) 21.8) 20 811 862) 4751.7) 25)
South Asia 46 593 497 (42 073 620, 3503.7 (3167.8, 5.3 (4.3, 6.3) 1 857 949 (1 633 946, 149.2 (130.6, 6.6 ( 21.1, 6.7) 46 024 719 (40 617 777, 3191.9 (2818.6, 8.3 ( 22.9, 5.8)
51 726 128) 3890.1) 2 091 633) 167.9) 52 015 817) 3596.2)
Southeast Asia 9 994 586 (8 824 830, 1713.4 (1515.6, 0.8 ( 0.5, 2.2) 588 556 (527 652, 112.6 (100.5, 4.3 ( 16.3, 7.5) 13 802 797 (12 437 848, 2263.3 (2041.4, 5.2 ( 16.7, 7.4)
11 416 565) 1953.3) 644 283) 122.9) 15 219 165) 2479.5)
Continued
423

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 424

Table 1 Continued

Prevalence (95% UI) Deaths (95% UI) DALYs (95% UI)

........................................................................................... .................................................................................... ...........................................................................................
No (95% UI) ASRs per Percentage No (95% UI) ASRs per Percentage No (95% UI) ASRs per Percentage
100 000 (95% change in ASRs 100 000 (95% change in ASRs 100 000 (95% change in ASRs
UI) between 1990 UI) between 1990 UI) between 1990
and 2019 and 2019 and 2019
..........................................................................................................................................................................................................................................................................................................
East Asia 46 648 756 (40 426 797, 2312.7 (2023.5, 6 (4.4, 7.7) 1 926 477 (1 662 056, 114.3 (98.9, 128.7) 15.8 ( 1, 36.1) 35 755 248 (30 993 511, 1868.7 (1623.9, 1.4 ( 13.8, 20.9)
54 086 511) 2661) 2 182 277) 40 770 086) 2120)
Oceania 164 330 (143 937, 2506.2 (2212.9, 4.1 (2.1, 6.3) 12 296 (9869, 198.9 (162.3, 8.3 ( 8.6, 29.3) 356 825 (282 888, 4529 (3654.6, 6.1 ( 11.9, 29.1)
189 495) 2851.2) 15 450) 246.6) 455 538) 5673.9)
Western 3 488 041 (3 125 754, 1964.2 (1759.8, 10.2 (9, 11.4) 166 504 (139 342, 114.6 (95.9, 132.2) 9.5 ( 31.9, 7.2) 3 707 833 (3 056 574, 2059.8 (1726.3, 10.9 ( 32.1, 7.1)
Sub Saharan 3 902 690) 2202.9) 195 399) 4 427 893) 2417.5)
Africa
Eastern 3 041 827 (2 698 118, 1950.1 (1728, 5.6 (4.5, 6.7) 120 310 (96 907, 93.6 (74.7, 112) 6.1 ( 28, 13.3) 2 912 202 (2 378 618, 1788.7 (1453.6, 10.9 ( 32.5,
Sub Saharan 3 440 456) 2210.8) 143 565) 3 490 483) 2129.2) 10.3)
Africa
Central 849 296 (775 177, 1721.2 (1566.7, 4.7 ( 7, 2.5) 47 752 (36 504, 116.8 (89, 150.5) 10.4 ( 27.4, 1 179 340 (907 739, 2251.5 (1730.8, 14.4 ( 31.3, 7.5)
Sub Saharan 931 776) 1888) 62 352) 10.5) 1 538 280) 2926)
Africa
Southern Sub- 1 147 619 (1 031 497, 2129.4 (1909.9, 3.7 ( 4.7, 2.7) 43 851 (39 702, 93.6 (84.4, 102.1) 4.6 ( 4.1, 14.8) 964 215 (873 974, 1748.3 (1589.2, 3.5 ( 12.3, 6.2)
Saharan Africa 1 278 706) 2383.5) 48 020) 1 063 477) 1919)

Generated from data available from http://ghdx.healthdata.org/gbd-results-tool.

S. Safiri et al.

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Burden of IHD, 1990–2019 425

Prevalence per 100 000

949 to <1500 4000 to <4500
1500 to <2000 4500 to <5000
2000 to <2500 5000 to <5500
2500 to <3000 5500 to <6000
3000 to <3500 6000 to <6199
3500 to <4000

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Eastern
West Africa Mediterranean
Caribbean and Central America Persian Gulf Balkan Peninsula Southeast Asia

Northern Europe

Figure 1 Age-standardized prevalence of ischemic heart disease per 100 000 population in 2019, by country. (Generated from data available from
http://ghdx.healthdata.org/gbd-results-tool).

65.4 to 61.9)] had the largest decreases during the measurement
period (Table 1). At the regional-level, the sex-specific estimates for
the percentage change in the age-standardized DALY rates from
IHD, during 1990–2019, can be found in Supplementary material on-
line, Figure S6.
National level
In 2019, the age-standardized prevalence of IHD ranged from 949.6 to
6198.5 per 100 000 people for the 204 countries and territories. Iran
[6198.5 (95% UI: 5644.4 to 6814.6)], Egypt [5623.9 (95% UI: 5255.3 to
6014.9)], and Kuwait [5583.1 (95% UI: 5166.6 to 6015.9)] had the high-
est age-standardized prevalence of IHD. In contrast, the Republic of
Korea [949.6 (95% UI: 871.0 to 1039.1)], Argentina [1057.6 (95% UI:
974.2 to 1149.3)], and Japan [1084.0 (95% UI: 979.1 to 1196.8)] had the
lowest age-standardized prevalence of IHD (Figure 1). The age-standar-
dized death rate due to IHD also varied substantially by country in 2019
(from 29.9 to 707.5 per 100 000 people). Uzbekistan [707.5 (95% UI:
638.2 to 780.7)], Azerbaijan [452.6 (95% UI: 399.8 to 506.8)], and
Tajikistan [439.2 (95% UI: 376.6 to 515.8)] had the highest age-standar-
dized death rates from IHD. In contrast, Japan [29.9 (95% UI: 25.1 to
32.5)], the Republic of Korea [35.0 (95% UI: 29.5 to 40.6)], and France
[38.4 (95% UI: 33.5 to 41.9)] had the lowest rates in 2019 (Figure 2). In
2019, Uzbekistan [11 116.3 (95% UI: 9840.3 to 12 505.4)], the Solomon
Islands [10 714.6 (95% UI: 8601.7 to 1287.2)], and Nauru [8278.6 (95%
UI: 6695.7 to 10 075.0)] had the highest age-standardized DALY rates
for IHD. In contrast, the Republic of Korea [517.8 (95% UI: 457.8 to
585.4)], Japan [529.5 (95% UI: 482.5 to 559.3)], and France [634.3 (95%
UI: 586.3 to 675.6)] had the lowest rates (Supplementary material on-
line, Figure S7).
.. There were also substantial differences in the percentage change
..
.. in the age-standardized prevalence of IHD during 1990–2019, with
.. Uzbekistan [27.6% (95% UI: 23.1 to 32.4)], Chad [17.1% (95% UI:
..
.. 13.3 to 21.0)], and Guinea [16.9% (95% UI: 13.0 to 21.0)] showing the
..
.. largest increases. In contrast, the USA [ 37.1% (95% UI: 39.3 to
.. 34.8)], Denmark [ 29.3% (95% UI: 32.7 to 25.4)], and Finland
..
.. [ 29.2% (95% UI: 32.6 to 22.6)] showed the largest decreases
.. across this period (Supplementary material online, Table S3). The
..
.. percentage change in the age-standardized death rates due to IHD
.. (from 1990 to 2019) also differed substantially between countries.
..
.. The largest increases were seen in Uzbekistan [119.0% (95% UI: 96.3
.. to 143.3)], Tajikistan [82.1% (95% UI: 53.7 to 116.8)], and Lesotho
..
.. [46.1% (95% UI: 10.1 to 92.3)]. In contrast, the largest decreases dur-
..
.. ing this period were found in the Republic of Korea [ 76.3% (95%
.. UI: 79.2 to 72.0)], Denmark [ 73.5% (95% UI: 75.2 to 71.7)],
..
.. and Norway [ 69.0% (95% UI: 71.0 to 66.7)] (Supplementary
.. material online, Table S4). Furthermore, the percentage change in the
..
.. age-standardized DALY rate from 1990 to 2019 also differed sub-
.. stantially by country. The largest increases were seen in Uzbekistan
..
.. [96.8% (95% UI: 72.8 to 121.8)], the Philippines [78.9% (95% UI: 28.9
.. to 117.8)], and Tajikistan [52.7% (95% UI: 27.3 to 84.5)]. In contrast,
..
.. the largest decreases during this period were found in the Republic
..
.. of Korea [ 79.6% (95% UI: 81.8 to 75.6)], Denmark [ 76.2%
.. (95% UI: 77.7 to 74.8)], and Norway [ 73.6% (95% UI: 74.9 to
..
.. 71.7)] (Supplementary material online, Table S5).
..
..
.. Age and sex patterns
.. In 2019, the global prevalence of IHD was higher among males across
..
. all age groups and peaked in the 85–89 and 90–94 age groups for
426 S. Safiri et al.

Deaths per 100 000

29 to <50 250 to <300
50 to <100 300 to <350
100 to <150 350 to <400
150 to <200 ≥400
200 to <250

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Figure 2 Age-standardized death rate of ischemic heart disease per 100 000 population in 2019, by country. (Generated from data available from
http://ghdx.healthdata.org/gbd-results-tool).

Figure 3 Global number of prevalent cases and prevalence of ischemic heart disease per 100 000 population in 2019, by age and sex. Dotted and
dashed lines indicate 95% upper and lower uncertainty intervals, respectively. (Generated from data available from http://ghdx.healthdata.org/gbd-
results-tool).

..
males and females, respectively. However, the global number of .. respectively (Figure 3). Also, in 2019, the global death rate due to IHD
prevalent cases was higher in males up to the 80–84 age group and .. was higher in males, than females, across all age groups and peaked in
..
peaked in the 65–69 and 70–74 age groups in males and females, .. the oldest age group. The global number of deaths was higher in
Burden of IHD, 1990–2019 427

..
males, than females, up to the 75–79 age group and peaked in the .. differences in the per cent of attributable DALYs were found for high
80–84 age group for both sexes (Supplementary material online, .. SBP (from 46.6% in 95 plus years to 60.1% in 60–64 years), high LDL
..
Figure S8). .. cholesterol (from 29.2% in 70–74 years to 74.8% in 35–39 years),
In 2019, the global DALY rate of IHD was higher among males .. smoking (from 1.6% in 95 plus years to 37.7% in 50–54 years), high
..
across all age groups and peaked in the oldest group. Furthermore, .. FPG (from 11.9% in 35–39 years to 28.6% in 75–79 years), high BMI
the global number of DALYs due to IHD was higher in males, than
.. (from 9.5% in 80–84 years to 40.2% in 25–29 years), ambient particu-
..
females, up to the 75–79 age group and peaked in the 60–64 and .. late matter (from 4.4% in 95 plus years to 31.4% in 25–29 years), and
80–84 age groups in males and females, respectively (Supplementary
.. having a diet low in whole grains (from 13.9% in 95 plus years to
..
material online, Figure S9). .. 29.9% in 25–29 years) (Supplementary material online, Figure S13).
.. The proportion of DALYs attributable to the individual risk factors
..
Burden of ischemic heart disease by .. also differed by age group for males and females (Supplementary ma-
..
socio-demographic index .. terial online, Figures S14 and S15, respectively).
At the regional-level, there was a bimodal association between the
..
..

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age-standardized DALY rate of IHD and SDI over the period ..
1990–2019. The global age standardized DALY rate per 100 000
..
..
Discussion
population was higher than expected, based on SDI, between 1990 ..
.. This study reported the prevalence, death, and DALY counts and
and 1997, but was lower than expected from 1998 until 2019. High- .. age-standardized rates for IHD in 204 countries and territories, from
income North America had a higher than expected DALY rate during ..
.. 1990 to 2019. Globally, there were 197.2 million (95% UI: 177.7 to
the majority of the measurement period, while Eastern Europe, .. 219.5) prevalent cases, 9.1 million (95% UI: 8.4 to 9.7) deaths, and
Central Asia, North Africa, and Middle East and Oceania had higher ..
.. 182.0 million (95% UI: 170.2 to 193.5) DALYs for IHD in 2019. This
than expected levels throughout the measurement period. The .. study also found that the age-standardized prevalence [2421.0 (95%
Central Europe region was higher than expected between 1990 and
..
.. UI: 2180.5 to 2692.6)], deaths [118.0 (95% UI: 107.8 to 125.9)], and
1999, while South Asia was higher than expected in the nine most re- .. DALY [2243.5 (95% UI: 2098.7 to 2385.0)] rates were high.
cent years. The remaining regions had lower than expected DALY
..
.. Previous research reported that in 2008 there were 7 249 000
rates for the most recent years (Figure 4). .. deaths globally from IHD, which is lower than the number of deaths
..
In 2019, there was a non-linear, but generally negative association .. in our estimate for the same time [8 930 369 (95% UI: 8 790 696 to
between the age-standardized DALY rates due to IHD and each .. 9 138 680)]. This discrepancy may relate to population growth, popu-
..
countries and territories SDI. The burden of IHD was not limited to .. lation ageing, and proportional changes in the death rates.11 Our
developed countries, as there were countries with much higher than .. study found that in 2019, China [1 874 007 (95% UI: 1 612 111 to
..
expected burdens in both developed and less developed regions. In .. 2 131 822)], India [1 519 124 (95% UI: 1 311 372 to 1 745 629)], and
2019, Uzbekistan, Afghanistan, Tajikistan, Egypt, Ukraine, Azerbaijan, ..
.. the Russian Federation [562 609 (95% UI: 488 817 to 632 969)] had
Turkmenistan, and many other countries had much higher than .. the largest number of deaths due to IHD. In contrast, a previous
expected burdens from IHD. In contrast, in 2019, there were also
..
.. study of 71 countries found that in 2010, the greatest number of
several countries, such as Portugal, Chile, United Republic of .. deaths were found in Russia, the USA, and Ukraine.7 This highlights
Tanzania, South Sudan, and Ethiopia, which had much lower than
..
.. geographic shifts in the burden of IHD both regionally and at a state
expected rates of burdens from IHD (Supplementary material online, .. level. In addition, a study in India reported that in 2015 there were
..
Figure S10). .. 0.9 million deaths due to IHD among people aged 30–69 years,12
.. which is closer to our 2019 estimates, since we found 768 102 deaths
..
Risk factors .. due to IHD in India for the aforementioned age group.
The percentage of DALYs due to IHD which was attributable to the .. The age-standardized death rate due solely to IHD has not been
..
individual risk factors differed at the global and regional levels. .. reported in previous global research and in several of these studies
Globally, high SBP (54.6%), high LDL cholesterol (46.6%), smoking .. the age-standardized rates were only reported for all CVDs com-
..
(23.9%), high fasting plasma glucose (23.8%), and high BMI (22.7%) .. bined.6 However, a Chinese study using GBD data found that in 2015
had attributable DALYs above 20%. There were large variations in
.. the age-standardized death rate due to IHD was 114.8 (95% UI:
..
the proportion of attributable DALYs for each region for high SBP .. 109.8–120.1),13 whereas our study found it to be 116.4 (95% UI:
..
(from 42.9% in Andean Latin America to 62.8% in Southern Sub- .. 100.3–131.5) in 2019. Another study14 reported the 2015 age-stand-
Saharan Africa), high LDL cholesterol (from 37.5% in Eastern Sub- .. ardized death rates due to IHD to be: Eastern Europe [males: 379.1
..
Saharan Africa to 55.1% in Oceania), high FPG (from 14.3% in Eastern .. (95% UI: 333.8 to 423.4); females: 224.3 (95% UI: 193.8 to 250.3)],
Sub-Saharan Africa to 36.0% in Oceania), and high BMI (from 10.3% .. Central Europe [males: 202.4 (95% UI: 177.6 to 227); females: 127.6
..
in High-income Asia-Pacific to 35.4% in North Africa and the Middle .. (95% UI: 109.0 to 144.2)], and Central Asia [males: 448.7 (95% UI:
East) (Figure 5). The per cent of DALYs due to IHD which was attrib- .. 412.5 to 485.6); females: 298.2 (95% UI: 272.0 to 322.8)]. These was
..
utable to each risk factor across the GBD regions are presented sep- .. close to our 2019 estimates for Eastern Europe [males: 409.9 (95%
arately for males and females in Supplementary material online, .. UI: 405.1 to 420.6); females: 223.4 (95% UI: 220.8 to 228.2)], Central
..
Figures S11 and S12, respectively. .. Europe [males: 212.5 (95% UI: 209.1 to 219.4); females: 129.0 (95%
There were also patterns in the percentage of DALYs due to IHD
.. UI: 126.5 to 133.5)], and Central Asia [males: 485.6 (95% UI: 471.5 to
..
which were attributable to risk factors by age-group. Large . 501.5); females: 272.5 (95% UI: 264.0 to 281.7)]. It is important to
428 S. Safiri et al.

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Figure 4 Age-standardized DALY rates for ischemic heart disease for the 21 Global Burden of Disease regions by socio-demographic index, 1990–
2019. Expected values based on socio-demographic index and disease rates in all locations are shown as the black line. DALY, disability-adjusted life
year. (Generated from data available from http://ghdx.healthdata.org/gbd-results-tool).

Figure 5 Percentage of DALYs due to IHD which were attributable to each risk factor for the 21 Global Burden of Disease regions, 2019, for both
sexes. DALY, disability-adjusted life year. (Generated from data available from http://ghdx.healthdata.org/gbd-results-tool).
Burden of IHD, 1990–2019
..
note that the age-standardized rates reported in these two studies
are comparable, as the same standard population was used in the
standardization process.
This study also found that the global age-standardized prevalence
[ 4.6% (95% UI: 5.7 to 3.6)], death [ 30.8% (95% UI: 34.8 to
27.2)], and DALY [ 28.6% (95% UI: 33.3 to 24.2)] rates have
all decreased substantially from 1990 to 2019. However, strikingly
there were several countries which had rising death rates for IHD,
including Uzbekistan, Tajikistan, and Lesotho. Urgent international at-
tention must be directed to address this geographic disparity in health
outcomes. Furthermore, the trend in the age-standardized death and
DALY rates due to IHD have been previously reported globally, or
for some selected countries, with findings similar to ours.7,11–15 This
study also demonstrates the importance of using country-specific in-
formation about IHD to inform local prevention strategies, since
using global- or regional-level data may not account for nuances of
the target population.
This study also estimated the global age-standardized prevalence
and death rates by age and sex. We found males had higher age-
standardized prevalence and death rates compared to females. In
addition, prevalence peaked in the 85–89 and 90–94 age groups for
males and females, respectively. For each sex, the death rate peaked
in the oldest age group. Previous research has also found age-related
differences in the death rates due to IHD7,11; however, no prior study
has investigated sex differences in the age-standardized prevalence.
These findings suggest that there may be a role for more targeted
preventative programmes for men and older populations.
In addition, our study found a non-linear, but generally negative, as-
sociation between the burden of IHD and each countries level of de-
velopment. Broadly, countries with higher SDI levels generally had a
lower IHD burden. However, the health system performance of the
countries should not be judged based on the observed burden alone.
Rather, each country’s observed burden should be compared with its
expected burden in order to identify preventable causes. To the best
of our knowledge, no previous study has examined the association
between a countries development level and their IHD burden. We
also found that the global-level patterns in the burden of IHD were
not very representative, and that national-level patterns should be
preferred when making health-related decisions.
Finally, this study identified a number of important risk factors for
IHD, the majority of which are modifiable, including hypertension,
increased LDL, obesity, high fasting plasma glucose, smoking, insuffi-
cient physical activity, and poor diet. This highlights the important
role of risk factor modification in reducing the burden of IHD.
Findings supported by results from the seminal INTERHEART study,
where potentially modifiable risk factors accounted for the vast ma-
jority of population attributable risk for first MI.16 There are a number
of evidence based strategies that are known to significantly reduce
disease burden for conditions, such as IHD. First, preventing the de-
velopment of modifiable risk factors, e.g. tobacco smoking, through
primordial prevention campaigns represents a highly effective and
underutilized approach, as demonstrated in our Cochrane systematic
reviews.17,18 Second, through targeted primary prevention policy
including the recognition and aggressive treatment of established risk
factors in high-risk populations, specifically diabetes, hypertension,
and dyslipidaemia. An example in the context of smoking cessation
429
.. includes interventions successfully targeted directly to cigarette
.. smokers with established co-morbidities,19 via health professionals,20
..
.. and in community pharmacy settings.21 Third, in patients with estab-
.. lished IHD, evidence based secondary prevention therapies are
..
.. required to reduce recurrence of AMI, the development of heart fail-
.. ure, and prevent excess mortality. Furthermore, as the current study
..
.. indicates that the burden of IHD is negatively associated with a coun-
.. tries SDI, resources and international policy attention should be pri-
..
.. oritized, focusing on countries with the highest prevalence and
.. poorest outcomes. Tailoring health interventions to the needs of
..
.. each consumer cohort while adjusting for environmental and social
..
.. factors is important to maximize value for money. There are a num-
.. ber of frameworks available to support the development of high-
..
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.. value and low-cost health promotion interventions. For example,
.. intervention mapping is a well-established stepwise approach used to
..
.. support development and increase the likelihood of effectiveness for
.. health interventions, by engaging key stakeholders, community mem-
..
.. bers, and/or patients in the planning and delivery process.22 In add-
.. ition to tailoring the intervention to the needs of the target end user
..
.. cohorts, it is also important to consider the context of implementa-
.. tion to identify roadblocks before resources are heavily invested into
..
.. what could be an ineffective policy or programme. For example the
.. RE-AIM (reach, effectiveness, adoption, implementation, and main-
..
.. tenance) framework provides a rigorous construct for policy makers
.. that will increase the sustainable adoption and implementation of ef-
..
.. fective, generalizable, and evidence-based interventions.23,24
..
.. Regardless of the approach chosen to mitigate IHD risk factors, fore-
.. thought, and tailoring to the contextual needs of the target audience
..
.. are essential.
..
..
.. Strengths and limitations
.. This study had several limitations. Firstly, there was no data for some
..
.. countries and so the burden of IHD for those countries was esti-
.. mated using the GBD modelling process. This study highlights the
..
.. need for better data in health systems to allow the monitoring of dis-
.. eases and risk factors and the evaluation of the effectiveness of
..
.. population-based interventions. Secondly, the attributable risk fac-
.. tors of IHD in this report were assumed to be independent and joint
..
.. distributions were not considered, which could inflate our estimated
.. PAFs. Thirdly, subnational estimates have not been provided for sev-
..
.. eral countries, although several studies have indicated large variations
..
.. within these countries for diseases and risk factors. Fourthly, we
.. were not able to include abdominal obesity as a risk factor, in addition
..
.. to BMI, despite emerging evidence that obesity-associated CVDs
.. show variations across regions and ethnicities. In particular, there are
..
.. distinctive patterns of abdominal obesity that contribute to an
.. increased CVD risk in South Asians, to such an extent that abdominal
..
.. obesity can be considered an independent risk factor.25,26 Therefore,
.. BMI should not be the only obesity-related cardiovascular risk factor
..
.. used for all population groups.27–29
..
..
..
.. Conclusion
..
..
.. Ischemic heart disease continues to be a major public health chal-
.. lenge, with large inter-country variations in the burden of this disease.
..
. Although the global age-standardized prevalence, death, and DALY
430 S. Safiri et al.

..
rates have generally decreased since 1990, there are still regions and .. Temesgen AM, Mokdad A, Moran AE, Muntner P, Narula J, Neal B, Ntsekhe M,
countries that exhibited increases. There was a non-linear, but gener- .. Moraes de Oliveira G, Otto C, Owolabi M, Pratt M, Rajagopalan S, Reitsma M,
.. Ribeiro ALP, Rigotti N, Rodgers A, Sable C, Shakil S, Sliwa-Hahnle K, Stark B,
ally negative association between IHD burden and the SDI of each .. Sundström J, Timpel P, Tleyjeh IM, Valgimigli M, Vos T, Whelton PK, Yacoub M,
country and territory. Prevention and control programmes should .. Zuhlke L, Murray C, Fuster V; GBD-NHLBI-JACC Global Burden of
.. Cardiovascular Diseases Writing Group. Global burden of cardiovascular dis-
be implemented to decrease population exposure to these risk fac- ..
tors, reduce the risk of IHD in high-risk populations, provide appro-
.. eases and risk factors, 1990–2019: update from the GBD 2019 study. J Am Coll
.. Cardiol 2020;76:2982–3021.
priate care for communities, increase population awareness of IHD .. 3. Bonita R, Magnusson R, Bovet P, Zhao D, Malta DC, Geneau R, Suh I,

and its risk factors, and to improve health data to enable better moni-
.. Thankappan KR, McKee M, Hospedales J, de Courten M, Capewell S, Beaglehole
.. R. Country actions to meet UN commitments on non-communicable diseases: a
toring of this disease. .. stepwise approach. Lancet 2013;381:575–584.
.. 4. World Health Organization. World Health Statistics 2016: Monitoring Health for the
..
.. SDGs Sustainable Development Goals. Geneva, Switzerland: World Health

Supplementary material .. Organization; 2016.

.. 5. Roth GA, Huffman MD, Moran AE, Feigin V, Mensah GA, Naghavi M, Murray
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.. 6. Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, Ahmed M,
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.. Castillo-Rivas J, Catalá-López F, Choi J-Y, Christensen H, Cirillo M, Cooper L,
.. Criqui M, Cundiff D, Damasceno A, Dandona L, Dandona R, Davletov K,
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..
.. EJA, Esteghamati A, Farid T, Farvid M, Feigin V, Ding EL, Fowkes G, Gebrehiwot
the Social Determinants of Health Research Center at the Shahid .. T, Gillum R, Gold A, Gona P, Gupta R, Habtewold TD, Hafezi-Nejad N, Hailu T,
.. Hailu GB, Hankey G, Hassen HY, Abate KH, Havmoeller R, Hay SI, Horino M,
Beheshti University of Medical Sciences, Tehran, Iran. .. Hotez PJ, Jacobsen K, James S, Javanbakht M, Jeemon P, John D, Jonas J, Kalkonde
.. Y, Karimkhani C, Kasaeian A, Khader Y, Khan A, Khang Y-H, Khera S, Khoja AT,
Funding .. Khubchandani J, Kim D, Kolte D, Kosen S, Krohn KJ, Kumar GA, Kwan GF, Lal
..
The Bill and Melinda Gates Foundation, who was not involved in any way .. DK, Larsson A, Linn S, Lopez A, Lotufo PA, El Razek HMA, Malekzadeh R,

in the preparation of this manuscript, funded the GBD study. The Shahid .. Mazidi M, Meier T, Meles KG, Mensah G, Meretoja A, Mezgebe H, Miller T,
.. Mirrakhimov E, Mohammed S, Moran AE, Musa KI, Narula J, Neal B, Ngalesoni F,
Beheshti University of Medical Sciences, Tehran, Iran (grant no. 26866) also .. Nguyen G, Obermeyer CM, Owolabi M, Patton G, Pedro J, Qato D, Qorbani M,
supported the present report. .. Rahimi K, Rai RK, Rawaf S, Ribeiro A, Safiri S, Salomon JA, Santos I, Santric
.. Milicevic M, Sartorius B, Schutte A, Sepanlou S, Shaikh MA, Shin M-J, Shishehbor
.. M, Shore H, Silva DAS, Sobngwi E, Stranges S, Swaminathan S, Tabarés-
..
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.. Truelsen T, Tyrovolas S, Ukwaja KN, Uthman O, Vasankari T, Vlassov V, Vollset
.. SE, Wakayo T, Watkins D, Weintraub R, Werdecker A, Westerman R,
The present study was approved by ethical committee of Shahid .. Wiysonge CS, Wolfe C, Workicho A, Xu G, Yano Y, Yip P, Yonemoto N,
.. Younis M, Yu C, Vos T, Naghavi M, Murray C. Global, Regional, and National
Beheshti University of Medical Sciences, Tehran, Iran (IR.SBMU.RET .. Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015.
ECH.REC.1399.1335). ..
.. J Am Coll Cardiol 2017;70:1–25.

Conflict of interest: none declared.

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