Cardiovascular disease (CVD) remains the leading cause of death in Europe, the Middle East and Africa, known as the EMEA region, a new report finds, which identifies high blood pressure as a primary cause of CVD worldwide. The report, published in the Dec. 20/27 special issue of the Journal of the American College of Cardiology (JACC), found ischemic heart disease was the leading cause of cardiovascular (CV) death, accounting for 9.44 million deaths in 2021 and 185 million disability-adjusted life years (DALYs). “We need to keep shining a light on the current state of CV health across the globe,” said Gregory A. Roth, MD, MPH, of the University of Washington, the senior author of the report. “Over 80% of cardiovascular disease is preventable. With this update, we are measuring some alarming global trends and reviewing the current interventions that can help countries make good, evidence-based choices for their health systems.” CVD mortality in Eastern Europe While CVD rates are high globally, Eastern Europe and Central Asia were estimated to have the highest rates of CVD mortality. Age-standardized CVD mortality rates in Eastern Europe ranged from 229.8 to 503.5 per 100,000 in 2021, representing a 2.2-fold difference regionwide. In this region, 17,866,169 prevalent cases of ischemic heart disease were recorded with 927,136 deaths and a DALYs rate of 4,420.5. Prevalence and death rates here were 4,978.0 and 253.5 per 100,000 age-standardized population, respectively. Prevalent cases of ischemic stroke totaled 3,098,259 in 2021, with 341,741 deaths recorded and a DALYs rate of 1,507.8 per 100,000. Prevalence and death rates here were 922.3 and 92.2, respectively. After ischemic heart disease and stroke, alcoholic cardiomyopathy had the highest age-standardized DALYs rate of 497.9. Among all CVD risks, high systolic blood pressure (SBP) accounted for the largest proportion of DALYs, at 49.6%. Non-rheumatic valvular heart disease had the largest percent increase (341.0%) in CVD cause-specific age standardized mortality rate since 1990 while rheumatic heart disease had the largest percent decrease at 79.9%. For age-standardized total cardiovascular disease, Eastern European countries of note included Ukraine (DALYs: 9,138.6, death and prevalence rate per 100,000: 503.5 and 7,486.6) and Belarus (DALYs: 8,708.8, death and prevalence rate: 469.5 and 7,155.0) in 2021. High SBP remains leading modifiable risk factor It was a similar case for the Central European region, with age-standardized CVD mortality rates ranging from 138.7 to 585.8 per 100,000 in 2021, a 4.2-fold difference across the region. Prevalent cases for ischemic heart disease totaled 7,098,279, with 340,777 deaths recorded. The death, prevalence, and DALY rate (per 100,000) was 145.6, 3,209.6, and 2,373.4, respectively. Figures for ischemic stroke recorded 1,630,757 prevalent cases with 164,142 deaths and a DALYs rate of 1,046.3. The death and prevalence rate were 67.9 and 779.5, respectively. After ischemic heart disease and stroke, hypertensive heart disease had the highest age-standardized DALY rate of 400.8. High SBP accounted for the largest proportion of DALYs at 54.4%. High SBP remains the leading modifiable risk factor for premature cardiovascular deaths, the report stated, accounting for 10.8 million CV deaths and 11.3 million deaths overall in 2021. The all-cause DALYs due to high blood pressure were 2,770 per 100,000 people. Other results of note saw non-rheumatic valvular heart disease achieving the largest percent increase in CVD cause-specific age standardized mortality rate since 1990 at 144.4%, while rheumatic heart disease had the largest percent decrease (79.0%). For age-standardized total cardiovascular disease, countries of note included Bulgaria (DALYs: 9,290.7, death and prevalence rate per 100,000: 535.8 and 7,102.1) and North Macedonia (DALYs: 8,644.2, death and prevalence rate: 585.8 and 6,714.7) in 2021. Western Europe and endocarditis The Western European region’s age-standardized CVD mortality rates ranged from 82.4 to 214.6 per 100,000 in 2021. This was a 2.6-fold difference across the region. Endocarditis had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 at 86.0%, while stroke had the largest percent decrease of 66.6%. The report recorded 95,993 prevalent cases of endocarditis with 19,624 deaths recorded in 2021. The DALYs, prevalence and death rate were 30.6, 12.9, and 1.7, respectively. Once again, ischemic heart disease was the highest recorded cardiovascular disease type for the region, with 13,390,457 prevalent cases noted and 581,161 deaths documented. The DALYs, prevalence, and death rate were 833.3, 1,488.1, and 50.6, respectively. The report recorded 5,589,186 prevalent cases and 232,019 deaths from ischemic stroke were also recorded for Western Europe with DALYs, prevalence, and death rates of 288.8, 629.6 and 18.0, respectively. After ischemic heart disease and stroke, the residual group of other cardiovascular disease had the highest age standardized DALY rate of 163. Among all CVD risks, high SBP accounted for the largest proportion of DALYs at 43.0%. For age-standardized total cardiovascular disease, countries of note included Cyprus (DALYs: 2,963.1, death and prevalence rate per 100,000: 214.6 and 5,127.0) and Greece (DALYs: 2,786.9, death and prevalence rate: 159.0 and 5,076.0) in 2021. Informing the global CV community Figures for cardiovascular disease in Central Sub-Saharan Africa highlighted a distinct epidemiology for the region as one of three (Central Asia and Eastern Europe) with the highest rates of CVD burden attributable to elevated SBP. After ischemic heart disease and stroke, hypertensive heart disease had the highest age-standardized DALY rate of 1193.1. Among all CVD risks, high SBP accounted for the largest proportion of DALYs at 55.7%. Other results found lower-extremity peripheral arterial disease had the largest percent increase in CVD cause specific age-standardized mortality rate since 1990 (43.0%), while rheumatic heart disease had the largest percent decrease (50.5%). The report recorded 383,265 prevalent cases of lower-extremity peripheral arterial disease in 2021, with 665 deaths and a prevalence rate of 777.7 per 100,000. The DALYs rate for the region was 32.7. Rheumatic heart disease was found in 2,283,857 prevalent cases with 2434 deaths recorded and a DALYs, prevalence, and death rate of 184.9, 1,666.3, and 4.0, respectively. Age-standardized CVD mortality rates in Central Sub-Saharan Africa ranged from 345.8 to 475.7 per 100,000 in 2021 – a 1.4-fold difference. Eastern Sub-Saharan Africa Other regions of Sub-Saharan Africa exhibited similar patterns, particularly Eastern Sub-Saharan Africa, with lower-extremity peripheral arterial disease also noted as the leading cause of death. The disease was responsible for 1,382 deaths in 2021, with 1,123,319 prevalent cases recorded and a DALYs rate of 21.7. Prevalence and death rates were 726.2 and 1.2, respectively. The condition also had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 at 45.3%, while rheumatic heart disease had the largest percent decrease (51.3%). Figures for rheumatic heart disease showed that there were 6,751,718 prevalent cases recorded with 6018 deaths and a DALYs, prevalence, and death rate of 157.6, 6,018, and 3.5, respectively. Ischemic heart disease incidences and deaths remained high with 3,771,203 prevalent cases and 104,976 deaths recorded. The DALYs, prevalence and death rates for this condition were 1,455.6, 2,237.6, and 73.0, respectively. Likewise, the incidences and deaths resulting from ischemic stroke were 1,922,321 and 56,442, respectively, with a DALYs rate of 845.9 noted. After ischemic heart disease and stroke, hypertensive heart disease had the highest age-standardized DALY rate of 787.9. Among all CVD risks, high SBP accounted for the largest proportion of DALYs at 53.9%. Further findings found age-standardized CVD mortality rates in Eastern Sub-Saharan Africa ranged from 195.4 to 429 per 100,000 in 2021- a 2.2-fold regionwide difference. Hypertensive heart disease Further findings, this time in the Southern Sub-Saharan African region, found that after ischemic heart disease and stroke, hypertensive heart disease had the highest age-standardized DALY rate of 1003.8. According to the report, there were 83,234 prevalent cases of hypertensive heart disease with 23,789 recorded deaths, giving prevalence and death rates of 155.9 and 50.3 per 100,000 in 2021, respectively. The DALYs rate here was given as 850.8. In addition, among all CVD risks, high SBP accounted for the largest proportion of DALYs at 56.6%. Lower-extremity peripheral arterial disease continued to be an issue for the region, with the condition having the largest percent increase in CVD cause specific age-standardized mortality rate since 1990 (55.1%). Rheumatic heart disease had the largest percent decrease at 33.9%. The report also found age-standardized CVD mortality rates in Southern Sub-Saharan Africa ranged from 268.2 to 456.2 per 100,000 in 2021, representing a 1.7-fold difference across the region. Findings for cardiovascular disease burden in Western Sub-Saharan Africa echoed those of the other Sub-Saharan African regions, with lower-extremity peripheral arterial disease and high blood pressure remaining significant challenges. Lower-extremity peripheral arterial disease had the largest percent increase in CVD cause specific age-standardized mortality rate since 1990 at 54.2%. The region recorded 1,368,699 prevalent cases with 1,959 deaths. Prevalence and death rates of 754.2 and 1.5, respectively, were recorded here, and the DALYs rate for the disease was 25.0. After ischemic heart disease and stroke, hypertensive heart disease had the highest age-standardized DALY rate of 600.5. Among all CVD risks, high SBP accounted for the largest proportion of DALYs at 54.4%. Meanwhile rheumatic heart disease recorded the largest percent decrease (69.2%) for the region with 5,360,391 prevalent cases noted and a prevalence rate of 1,148.6 per 100,000. Deaths from the disease reached 5,303, with a death rate calculated at 2.3 per 100,000 along with a DALYs rate of 117.8. Age-standardized CVD mortality rates in Western Sub-Saharan Africa ranged from 260.7 to 484.6 per 100,000 in 2021. This represented a 1.9-fold difference regionwide. CV disease burden in North Africa and Middle East Finally, within the EMEA region, the CV disease burden in North Africa and Middle East found that out of all regions investigated as part of the Global Burden of Diseases (GBD) report, it had the highest prevalence rate for age-standardized CVD, at 9,978.7 per 100,000. Age-standardized CVD mortality rates in North Africa and Middle East ranged from 134.2 to 600.2 per 100,000 in 2021, a relatively high 4.5-fold difference across the region. Lower-extremity peripheral arterial disease had the largest percent increase in CVD cause-specific age-standardized mortality rate since 1990 at 52.8%. The report recorded 4,527,335 prevalent cases and a prevalence rate of 1,039.3. Deaths from the disease reached 1,000 in 2021, with a death rate of 0.3 per 100,000 and a DALYs rate of 9.1. However, rheumatic heart disease recorded the largest percent decrease (60.8%) from 1990, with a prevalent cases and a rate of 3,604,934 and 541.0, respectively. Deaths from the disease reached 9,191, representing a death rate of 1.9 and a DALYs rate of 86.8. Among all CVD risks, high SBP accounted for the largest proportion of DALYs at 52.2%. “This visual atlas serves as a timely reminder about the importance of modifiable risk factors for heart disease, like high blood pressure,” concluded George A. Mensah, MD, an author of the paper “Deaths due to hypertension have steadily increased in the U.S. for the past 20 years, which mirrors trends in other regions and leaves researchers eager to find practical and innovative solutions,” said Dr Mensah, who is also director of the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute. “Of really great concern is the finding that high blood pressure control rates have progressively declined in the US over the last decade.” Sources: Vaduganathan M, Mensah GA, Turco JV, et al. The Global Burden of Cardiovascular Diseases and Risk: A Compass for Future Health. J Am Coll Cardiol 2022;80:2361-2371. Lindstrom M, DeCleene N, Dorsey H, et al. Global Burden of Cardiovascular Diseases and Risks Collaboration, 1990-2021. J Am Coll Cardiol 2022;80:2372-2425. Image Credit: Dmitriy Melnikov – stock.adobe.com