Introduction

Cardiovascular diseases (CVDs) are the leading cause of mortality globally, responsible for a significant number of deaths and disabilities. In 2021 alone, CVDs accounted for 20.5 million deaths, comprising approximately one-third of all global deaths [1]. While cardiovascular conditions were traditionally considered diseases of affluence, this is no longer the case. Over three-quarters of CVD-related deaths occur in low- and middle-income countries (LMICs) [2].

Moreover, these deaths are the primary contributor to premature non-communicable disease (NCD) mortality. Ischemic heart disease, specifically, stands as the leading cause of premature death in 146 countries for men and 98 countries for women [3]. The complexity of the global picture is exacerbated by the levels of inequalities in the impact of CVDs. Notably, LMICs experience higher rates of premature mortality from CVDs compared to high-income countries (HICs), while the reduction in age-standardised mortality rates is progressing more slowly in LMICs.

In May 2012 the World Health Assembly adopted the target of a 25% reduction in premature mortality from noncommunicable diseases by 2025. In May 2013 the NCD Global Monitoring Framework was launched during the World Health Assembly. Its primary objectives were to drive progress in the prevention and control of NCDs, serve as a foundation for advocacy, raise awareness, strengthen political commitment, and promote global action against NCDs. The framework encompassed nine voluntary global targets focused on behavioural and metabolic risk factors, as well as national healthcare system responses [4].

Over a decade has passed since international organisations and governments have been working towards achieving these global targets and reducing premature mortality. However, the current pace of decline is insufficient. Based on trends observed between 2010 and 2016, it is estimated that less than 20% of countries will achieve the UN Sustainable Development Goal Target 3.4 (SDG 3.4) – a one-third reduction in premature mortality from NCDs by 2030 [5]. Most countries, particularly those classified as low- or lower-middle income, need to accelerate progress to meet these targets.

This paper summarises the World Heart Report 2023,¹ which is a comprehensive overview of the trends and current landscape of the key dimensions of cardiovascular health. By synthesising epidemiological, policy, and economic data, the World Heart Report provides information that can help guide policymakers at national and international levels in identifying and addressing the most critical priorities to address cardiovascular conditions.

Methods and data

The analysis of the burden of cardiovascular diseases and associated risk in this study utilised data from global initiatives including the Global Burden of Disease Study [6], the NCD Risk Factor Collaboration [7], and the NCD Countdown 2030 initiative [3]. These have been extensively described elsewhere and are considered the most valid and reliable sources for global cardiovascular data. In selecting data sources, priority was given to those that offered a high level of disaggregation (by sex, age, country, region), data completeness, richness of the raw data informing the model, and comparability of estimates.

Absolute numbers of death, age-standardised death rates, and the probability of dying between 30 and 70 years of age² have been reported to describe the burden of cardiovascular mortality. Analysis of risk factors focused on nine specific factors. These factors were selected based on the six risk factors outlined in the WHO NCD Global Monitoring Framework, along with two additional risk factors—non-HDL cholesterol levels and air pollution. The inclusion of these two additional factors was based on their substantial impact on the prevalence and mortality rates of CVDs (Table 1).

To assess the risk factors’ country profiles, each country was ranked based on the level of the specific risk factor, ranging from the highest level to the lowest level. Subsequently, quintiles were generated for each risk factor, dividing the countries into five equal groups based on their respective levels of the risk factor.

To assess the association between CVD burden and health expenditure, additional data on Gross Domestic Product (GDP), Current Health Expenditure as a percentage of GDP (CHE), and Out of Pocket Expenditure (OOPS) were obtained from the WHO Global Health Expenditure database [8].

The World Heart Federation Policy Index (WHF Policy Index) provides an overview of national governments’ level of implementation of eight critical policies related to CVD health (Table 2). The expert panel of the WHF Advocacy Committee carefully selected these policy indicators as the most relevant for ensuring a healthy heart profile in populations. Data for the WHF Policy Index were obtained from the Global Health Observatory [9]. Each policy was assigned a score of 0 if it was not in place in the country and 1 if it was in place. The overall index score for each country ranged from 0 (no policies in place) to 8 (all policies in place). Complete information was available for 166 countries.

Trends and levels are presented for both regions and individual countries. Countries were classified into regions based on the Global Burden of Diseases classification, which includes Central Europe, Eastern Europe, Central Asia, and the High-Income region as distinct regions (https://www.healthdata.org/sites/default/files/files/Projects/GBD/GBDRegions_countries.pdf). This division into more regions allows for more detailed comparisons of mortality and risk factor rates across significant geographical areas. To assess the association between CVD burden and health expenditure indicators the Pearson’s correlation coefficient was used.

Results

The number of deaths due to acronym introduced in the introduction CVDs has increased over the years. In 1990, the estimated deaths stood at around 12.1 million [95% Uncertainty Interval: 11.4–12.6 million], equally distributed between men and women. By 2019, this number had risen to 18.6 million [17.1–19.7], with 9.6 million [8.9–10.3] deaths among men and 8.9 million [7.9–9.7] deaths among women (Figure 1). Overall, CVDs accounted for 33% of all global deaths in 2019, with ischemic heart disease (9.1 million deaths) and stroke (6.6 million deaths) contributing to 85% of CVD-related deaths. While the number of deaths due to CVDs over the last 30 years has increased, mostly due to the ageing and growth of the population, the age-standardised death rate, which accounts for changes in population demographics, has declined from 354.5 per 100,000 people [330.6–369.5] in 1990 to 239.9 per 100,000 people [219.4–254.9] in 2019 (Figure 2).

When examining regional trends, significant variations in the rate of decline in age-standardised CVD death rates become apparent (Figure 3). Between 1990 and 2019, all regions experienced a decline in age-standardised CVD death rates, but there are signs of this decline slowing down in the past decade. The High-income region exhibited the fastest average rate of decline for both men and women, with an average annual rate of change of 2.6%. On the other hand, the South Asia, the Southeast Asia, East Asia and Oceania, and the Sub-Saharan Africa regions had the slowest rates of decline. Notably, there was almost no improvement in CVD death rates for men in these regions.

In 1990, male age-standardised CVD death rates in the Sub-Saharan Africa region were 1.2 times higher than those observed in the High-income region. However, by 2019, the age-standardised rates in the Sub-Saharan Africa region were 2.1 times higher than those in the High-income region. For women in 2019, only the Latin America and the Caribbean region achieved CVDs death rates levels comparable to those observed in the High-income region in 1990, almost three decades before.

The Central Europe, Eastern Europe, and Central Asia region had the highest age-standardised death rates for males and females in both 1990 (670.2 [644.4–683.3] and 467.2 [436.4–481.7] deaths per 100,000 people respectively) and 2019 (524.1 [475.4–566.9] and 345.7 [308.1–376.3] deaths per 100,000 people respectively).

The North Africa and Middle East region had the second highest death rates for males (376.7 per 100,000 people [336.5–414.7] and females (339.8 per 100,000 people [298.9–374.2]) in 2019.

Ischemic heart disease stands as the leading cause of CVD mortality across all regions, except for women in Sub-Saharan Africa. Notably, in 2019, the death rate for cardiomyopathy and myocarditis among males in Central Europe, Eastern Europe, and Central Asia was more than three times higher (28.5 per 100,000 people [20.3–32.9]) than in the second highest region (Sub-Saharan Africa, 8.4 per 100,000 people [5.8–10.6]) and thirty times higher than the region with the lowest rates (South Asia, 0.8 per 100,000 people [0.6–1.1]).

Discussion

In this paper we summarise the burden of CVDs, associated risk factors, the association between national health expenditures and CVD burden, and the role of critical policies, as presented in the World Heart Report 2023.

Cardiovascular diseases have remained the leading cause of mortality for over three decades, accounting for approximately one-third of all global deaths, with 20.5 million deaths recorded in 2021 [1]. The decline in CVD death rates has been faster in high-income countries compared to low- and middle-income countries, where over 80% of CVD deaths currently occur. Globally, CVDs have consistently been the leading cause of deaths over the last three decades. The Central Europe, Eastern Europe, and Central Asia region continue to face the highest levels of CVD mortality globally. Results indicate that although CVD mortality levels are generally lower in women than in men, almost 30% of countries in the North Africa and Middle East region and the Sub-Saharan Africa region (mainly West African countries) report higher CVD mortality rates for females than males. The association between health expenditure as a percentage of GDP, out-of-pocket expenditure, and CVD mortality highlights the need for adequate investment in healthcare systems to mitigate the burden of CVD. In terms of risk factors, raised blood pressure is the leading global CVD risk factor, contributing to approximately 10 million deaths in 2019. Most CVD risk factors, including physical inactivity, alcohol consumption, tobacco smoking, raised blood pressure, and diabetes, are more prevalent in men compared to women, with obesity being the only risk factor higher in women.

While the data presented here provide a detailed picture of the current burden of CVDs, there are some important limitations. The data used to present the temporal burden of CVDs and associated risk factors are derived from complex modelling [10, 11]. Richness/lack of data informing the model is statistically expressed through the levels of uncertainty. Here, for simplicity, we have not systematically reported the associated levels of uncertainty. In particular, the lack of data from low- and middle-income countries, results in larger levels of uncertainty in those countries.

There is no one-size-fits-all approach to improving cardiovascular health globally. Every population is susceptible to different risk factors based on where they live and their lifestyles. Whether that is having higher prevalence of tobacco and alcohol use and higher sodium intake or being more exposed to dangerous levels of air pollution and having lower levels of physical activity. This means that decision makers and stakeholders must look closely at the risk factor prevalence in their countries and regions to fully understand what policy areas need more focus to get cardiovascular health moving in the right direction. There are, however, baseline approaches that every country should implement as a foundation from which to build tailored activities to tackle CVDs. This includes implementing major policy initiatives that are essential to improving CVD health, such as National Tobacco Control Programmes, securing the availability of CVD drugs, and creating an Operational Unit in the Ministry of Health responsible for tackling NCDs. Additionally, it requires adequately funded health systems and initiatives so that all communities can access the care they need. The stalling progress in cardiovascular health is not unique. Almost every health initiative around the world suffered because of the COVID-19 pandemic and countries are now grappling with which areas to prioritise as they aim to boost and protect the health of their populations. Given the severe burden of CVDs both in terms of mortality and morbidity, this area of health cannot be neglected. The world will struggle to meet the ambitious targets set to reduce premature mortality from NCDs by 25% compared to 2010 levels, by 2025. There is still time, however, to accelerate action toward meeting Sustainable Development Goal 3.4 of reducing by one-third premature mortality from NCDs, including cardiovascular diseases.

To promote action against CVDs, several aspects should be considered in the short and long term. First, countries need to enhance data collection on CVDs and their risk factors, particularly in low- and middle-income countries where data gaps exist, to better understand populations at higher risk. Second, countries should aim for health expenditure of at least 5% of GDP, in line with WHO recommendations. Third, countries should implement evidence-based policies to address CVDs, considering the disease burden and prevalent risk factors, while ensuring adequate resources and monitoring for progress. Fourth, it is crucial to prioritise coverage of CVD prevention and management interventions within Universal Health Coverage (UHC) benefit packages to minimise out-of-pocket expenses. Fifth, lessons learned from successful CVD prevention, management, and improved access to care and therapies should be implemented across all regions to address inequities and uneven progress in reducing CVD mortality.

The WHF Policy Index described here provides a working tool for national governments to use to assess, monitor and improve implementation of policies addressing CVDs health. We must recognise that policies are only as strong as when they are enforced and evaluated. Here we attempt to begin capturing measures by which organisations and advocates can monitor the actions of key stakeholders like the government and other players at the national level.

It is imperative to take concerted action to combat cardiovascular diseases and work towards achieving the global targets set forth, thereby improving the health outcomes and well-being of populations worldwide.