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Cardiovascular disease burden in the North Africa and Middle East region: an analysis of the global burden of disease study 1990–2021

BMC Cardiovascular Disorders volume 24, Article number: 712 (2024) Cite this article

Abstract

Aims

Cardiovascular diseases (CVD) are a leading cause of mortality and morbidity in the North Africa and Middle East (NAME) region. Due to the paucity of research on this issue, we aimed to estimate the burden of CVD and its attributable risk factors in the NAME region.

Methods and results

Data from the Global Burden of Disease (GBD) were retrieved to estimate the incidence, prevalence, deaths, years of life lost, years lived with disability, disability-adjusted life years (DALYs) for CVD across 21 countries and both sexes. From 1990 to 2021, the incidence of CVD increased, but the age-standardized incidence rate slightly declined. The prevalence of CVD rose, with stable age-standardized prevalence rates. Additionally, the age-standardized DALY rate decreased from 11421.8 to 7353.8 per 100,000 people. Men consistently had higher rates of incidence, prevalence, deaths, and DALYs compared to women. Ischemic heart disease, stroke, and hypertensive heart disease were the leading causes of DALYs. Furthermore, high systolic blood pressure, dietary risks, and high LDL cholesterol were the top risk factors across NAME countries. countries with a history of war or ongoing conflict experience higher rates of death, disease burden (DALYs), and disease incidence compared to countries without such a history.

Conclusion

Despite the Progress in reducing the CVD burden in the NAME region, CVD remains a major public health problem, specifically due to significant sex disparities and various socio-economic factors. The study highlights the need for targeted interventions addressing these disparities and socio-economic determinants.

Clinical trial number

not applicable.

Lay summary

This study, using data from the Global Burden of Disease, reveals that despite some progress, cardiovascular disease (CVD) remains a major health issue in the North Africa and Middle East region, with significant sex disparities and a need for targeted interventions.

* While the overall age-standardized CVD incidence rate slightly declined, the prevalence and overall burden (number of DALYs) increased in the region between 1990 and 2021.

* High systolic blood pressure, dietary risks, and high LDL cholesterol were the leading risk factors for CVD in the NAME region, highlighting the importance of lifestyle interventions and healthcare access.

Peer Review reports

Introduction

Cardiovascular diseases (CVD) have remained the major cause of mortality and disability-adjusted life years (DALYs) worldwide, significantly impacting global public health with immense costs for society and the healthcare systems [1,2,3,4].

The North Africa and Middle East (NAME) region showcases a range of socio-economic strata, urban development levels, and healthcare structures reflecting its abundant diversity. The variations pose significant obstacles in delivering effective cardiovascular care, primarily due to variations in resources, infrastructure, and availability. Efforts to improve cardiovascular health in the region should focus on addressing these variations through comprehensive prevention and management strategies. In order to effectively reduce the impact of CVD, public health initiatives should focus on reducing obesity, promoting physical activity, encouraging healthy eating habits, and addressing air pollution [5,6,7].

The NAME region is currently undergoing a rapid epidemiological change, transitioning from infectious to non-infectious diseases as the primary health issue. This alteration is influenced by different factors like changes in dietary habits, increased use of tobacco, and sedentary behaviors [6, 8, 9]. Consequently, the prevalence of key risk factors for CVD such as hypertension, diabetes, and dyslipidemia has been on the rise in this area [10,11,12,13,14].

Between 1990 and 2019, the NAME region experienced a 140.9% increase in the absolute number of CVD cases. Despite this significant rise, the age-standardized prevalence of CVD showed a marginal decline of 1.3%. During the same period, the number of deaths attributed to CVD increased by 78.3%, yet the age-standardized mortality rates fell by 28% [15]. These changes, which vary among countries in the region, highlight the pressing necessity for tailored strategies and policies to prevent the rates of CVD morbidity and mortality.

We aimed to analyze and report the Global Burden of Diseases (GBD) 2021 estimations regarding CVD burden over the past three decades. This study explores the socio-economic, environmental, and healthcare-related factors influencing CVD burden. The results of the present study could offer valuable insights to health authorities and policymakers by providing a clearer perspective and guiding them toward more effective strategies to lower the burden of CVD and proper allocation of resources among the population in the future.

Methods

Data source

This study analyzed data from the 2021 GBD study which is an ongoing effort to estimate disease burden for every country in the world. The GBD 2021 study is coordinated by the Institute for Health Metrics nand Evaluation (IHME) and involves multinational collaborators to report a comprehensive estimation of 371 diseases and injuries and 81 risk factors in 204 countries. The detailed methods and data collection protocol have been published previously [16, 17]. The GBD study uses deidentified data, and a waiver of informed consent was reviewed and approved by the University of Washington Institutional Review Board.

Data availability

The data underlying this article are available at https://vizhub.healthdata.org/gbd-results/.

Definition

GBD 2021 categorized diseases and injuries into 4 levels. CVD was classified as the second level and was divided into 12 types including Rheumatic heart disease (ICD code: I019), Ischemic heart disease (ICD code: I20-I25), Stroke (ICD code: I64), Hypertensive heart disease (ICD code: I11.0), Non-rheumatic valvular heart disease (ICD code: I35.9), Cardiomyopathy and myocarditis (ICD code: I51.4), Pulmonary arterial hypertension (ICD code: I27.21), Atrial fibrillation and flutter (ICD code: I48.9), Aortic aneurysm (ICD code: I71.9), Lower extremity Peripheral artery disease (ICD code: I73.9), Endocarditis (ICD code: I33.0), Other cardiovascular and circulatory diseases(ICD code: I52) [16]. Detailed diagnosis and definition of CVDs have been described in previous GBD reports [18].

The GBD 2021 study organizes a total of 88 risk factors into a hierarchical structure with four levels and an overarching aggregate of all risks. At Level 1, risks are categorized as environmental and occupational, behavioral, and metabolic. Level 2 disaggregates these into 20 specific risks or clusters, such as dietary risks and air pollution. Level 3 further breaks down into 42 more detailed risks. Level 4 consists of 22 specific risks. This hierarchy allows detailed evaluation of individual and grouped risk factors [17].

NAME, one of the seven GBD super-regions, was investigated in this study and included Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, Türkiye, the United Arab Emirates (UAE), and Yemen [19]. To further examine the effect of political conditions on CVD burden, we classified the 21 countries in the NAME region into two clusters based on political stability and conflict history:

Countries with a history of war and ongoing conflict: Afghanistan, Yemen, Iraq, Syria, Libya, Algeria,

Lebanon, Sudan and Palestine.

Relatively stable countries without a history of war or ongoing conflict: Bahrain, Egypt, Iran, Jordan,

Kuwait, Morocco, Oman, Qatar, Saudi Arabia, Tunisia, Türkiye, and the UAE.

Estimation method

The burden of CVD is represented by age-standardized rates (ASRs) and their 95% confidence intervals (CI) of incidence, prevalence, deaths, DALYs, years of life lost (YLLs), years lived with disability (YLDs), accounting for sex, country, and temporal comparisons. Incidence and prevalence are based on data from various sources including previous published studies and medical records and surveys and is estimated by using DisMod-MR version 2.1, a Bayesian regression analytical tool [16]. Deaths were estimated by using data from vital registration coded to the international classification of diseases and verbal autopsy as well as surveys, census, and surveillance systems [20]. YLLs are calculated from the number of deaths multiplied by the predicted life expectancy by age, sex, location, and year [20]. Each sequela prevalence is multiplied by a disability weight (DW) to estimate YLDs. The confidence intervals reported around YLDs incorporate uncertainty in prevalence and in the DW [16]. DALYs were calculated as the sum of YLLs and YLDs [18]. ASR is a measure that adjusts population rates to a standard age distribution, ensuring accurate comparisons across populations with different age structures [21].

Statistical analysis

In this study, we used the ASRs of incidence, prevalence, deaths, YLLs, YLDs, and DALYs to report the burden of CVD for NAME and its countries from 1990 to 2021.

The ASR (per 100,000 population) was calculated based on the GBD world population standard [22]. To measure the trends in the burden of CVDs, the Annual percentage change (APC) and corresponding 95% CI were calculated. The APC is calculated using a linear regression model applied to the natural logarithm of ASRs. The natural logarithm of the ASR (ln (ASR) is regressed on the calendar year using the model: ln (ASR) =α + βx+ɛ, where x = calendar year. The slope (β) reflects the trend over time in the ASR on a log scale. Using the linear regression model, the APC and its 95% CI were calculated as: y = 100× (exp (β) − 1), where y = APC [23, 24]. The sign and CIs of the APC indicate the direction and stability of the trend over the observation period. If the lower limit of the 95% CI of the APC is greater than 0, it indicates an increasing trend in ASRs. If the upper limit of the 95% CI is less than 0, it indicates a decreasing trend. If the 95% CI includes both positive and negative values, the ASR trend is considered constant. All estimates were presented with 95% Uncertainty Intervals. All of the statistical analyses and visualizations were done using R software version 4.1.1 (R Foundation for Statistical Computing, Vienna, Austria).

Ethical approval and consent to participate

Ethical approval

and informed consent were not required because the GBD data is publicly accessible and the analyses did not involve any identifiable information.

Results

Incidence & prevalence

From 1990 to 2021, there has been an increase in the incidence of CVD or the number of new cases per year. The age-standardized incidence rate shows a slight decline from 1336.5 (1212.7 to 1504.3) per 100,000 people to 1232.3 (1117.9 to 1378.3) people, indicating that the risk of developing CVD is not increasing as sharply as the raw numbers. The prevalence of CVD, or the total number of people living with the disease, has significantly increased.The age-standardized prevalence rate appears to be stable from 9660.1 (9201.3 to 10122.8) per 100,000 people to 9882.6 (9335.5 to 10467.5) per 100,000 people, suggesting that the proportion of the population with CVD is not rising as fast as the absolute numbers (Fig. 1, Figure S3,S4).

Fig. 1
figure 1

Time trend of ASR vs. all-age numbers of Mortality, DALYs, Incidence and Prevalence caused by CVDs in NAME region, both sexes, 1990 to 2021. Abbreviations: ASR, age-standardized rate; CVD, cardiovascular disease; DALYs: disability-adjusted life years; NAME, North Africa and Middle East

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In 2021, the United Arab Emirates had the highest age-standardized prevalence rate of CVD, with 11066.8 (10490.2 to 11668.2) cases per 100,000 people and, the Syrian Arab Republic had the highest age-standardized incidence rate of CVD in 2021, with 1480.4 (1334.6 to 1657) cases per 100,000 people. From 1990 to 2021, Saudi Arabia experienced the greatest relative increase of approximately 14.9% in the age-standardized prevalence rate of CVD, rising from 8633.6 (8235.9 to 9058.7) to 9918.3 (9320 to 10521.4) cases per 100,000 people. Afghanitan showed the most significant decrease in the age-standardized prevalence, dropping from 9832.2 (9387.2 to 10246.4) to 9632.4 (9097.4 to 10204.1) cases per 100,000 people during the same period. Moreover, Libya experienced the greatest relative increase of around 6.1% in the age-standardized incidence rate of CVD, climbing from 1178.1 (1000.4 to 1380.6) to 1249.9 (1076 to 1448.3) cases per 100,000 people. On the other hand, Tunisia showed the most significant decrease in the age-standardized prevalence, declining from 1155.8 (996.5 to 1336) to 1138.7 (1000.8 to 1311.2) cases per 100,000 people. (Fig. 2) (Table 1, Table S1, S2).

Fig. 2
figure 2

Ranking of NAME countries for ASR of Deaths, DALYs, Incidence and Prevalence caused by CVDs, 1990 to 2021. Abbreviations: ASR, age-standardized rate; CVD, cardiovascular disease; DALYs, disability-adjusted life years; NAME, North Africa and Middle East. Footnote: Rank increased, Rank constant, Rank decreased

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Fig. 3
figure 3

Heatmap of APC in DALYs for CVD Causes across NAME countries, 1990 to 2021. Abbreviations: APC, annual percentage change; CVD, cardiovascular disease; DALYs: disability-adjusted life years; NAME, North Africa and Middle East, IHD: Ischemic heart disease, STRK: stroke, AF/AFL: atrial fibrillation and flutter, CMP: cardiomyopathy and myocarditis, HHD: hypertensive heart disease, RHD: rheumatic heart disease, NRVHD: Non-Rheumatic valvular heart disease, AA: aortic aneurysm, LEPAD: lower extremity peripheral arterial disease, ENDC: endocarditis, PAH: Pulmonary arterial hypertension

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In 2021, the incidence rate of CVD was greater in men compared to women, with 1414.8 (1277.6 to 1595.1) cases per 100,000 people in men and 1042.8 (949.6 to 1153.5) cases per 100,000 people in women. Similarly, the prevalence rate of CVD was higher in men than in women in 2021, with 11086.8 (10451.2 to 11758.3) cases per 100,000 people in men and 8649 (8142.5 to 9163.5) cases per 100,000 people in women. (Figure S1, S2)

DALY

The number of DALYs due to CVD has increased significantly from 1990 to 2021. DALYs measure the overall disease burden, expressed as the number of years lost due to disability or early death. However, the age-standardized rate of DALYs has shown a declining trend from 11421.8 (10721.1 to 12113.7) per 100,000 people to 7353.8 (6598.6 to 8111.9) people indicating that while the total burden is increasing, the rate adjusted for age is decreasing. (Fig. 1, Figure S3)

In 2021, Afghanistan had the highest age-standardized rate of DALY due to CVD, with 12478.3 (10077.8 to 15039) cases per 100,000 people. From 1990 to 2021, Qatar experienced the greatest relative decrease in the age-standardized DALY rate of CVD, dropping from 11248.3 (9854.2 to 12776) to 3768.2 (3061.1 to 4489.7) cases per 100,000 people. Conversely, Afghanistan showed the most significant increase in age-standardized DALY, rising from 6771.3 (5671.1 to 7903.6) to 7072 (5688.2 to 8805.7) cases per 100,000 people during the same period. (Table 1, Table s1, S2)

Age-standardized rate of DALY was higher in males than in women in 2021 (8068.3 [7225.9 to 8978.5] per 100000 people in men and 6587.8 [5854.9 to 7274.8] per 100000 people in women) (Figure S1, S2).

However, DALY counts increase with age, peaking in the 70–74 years age group. Ischemic heart disease is the leading contributor to DALY, followed by stroke and Hypertensive heart disease. Atrial fibrillation flutter and cardiomyopathy and myocarditis frequently appeared in the middle rankings, with AF/AFL and CMP often showing a decrease in their burden but displaying varied trends across different countries. Rheumatic heart disease and non-rheumatic valvular heart disease appeared sporadically, more often in women, and usually with a decreasing trend. In Afghanistan, Pulmonary Arterial Hypertension has become the third highest cause of DALY, with the number increasing from 18.2 (9.2 to 29.2) in 1990 to 25.3 (11 to 39) in 2021. (Figures 4, 5, Figures S5, S6, S7)

Fig. 4
figure 4

Mortality and DALYs Due to CVD Causes of different age groups in NAME region, male vs. female, 2021. Abbreviations: CVD, cardiovascular disease; DALYs: disability-adjusted life years; NAME, North Africa and Middle East

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Fig. 5
figure 5

Comparison of CVD risk factors in different NAME countries in term of DALYs in both sexes, 2021. Abbreviations: CVD, cardiovascular disease; DALYs, disability-adjusted life years; NAME, North Africa and Middle East

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Significant DALY contributions are observed even in younger age groups (15–44 years), although they are lower compared to older age groups (45 + years). Males exhibit higher DALY rates in younger age groups (15–44 years) compared to females (Fig. 4).

Certain countries have higher scores in specific metrics, indicating elevated values. For instance, Iraq demonstrates higher values for YLL and DALYs, while Kuwait and Qatar exhibit lower values across these metrics, implying a reduced burden of cardiovascular diseases. The majority of countries display noteworthy values for DALYs and YLL, signifying that cardiovascular diseases significantly affect life expectancy and quality of life in the region. In radar charts, Lebanon scored high on YLL and DALYs, indicating a significant impact on population health. (Fig. 3, Figure S4, Figure S16-18)

CVD deaths

The number of deaths caused by CVD has risen considerably between 1990 and 2021. Despite this, the mortality rate adjusted for age has decreased from 529.2 (486.4 to 560.6) per 100,000 individuals to 363.5 (322.3 to 397.3) individuals, indicating a decline in the rate despite the increasing total number of deaths. (Fig. 1, Figure S3)

The age-standardized death rate of CVD was higher in men than in women between 1990 and 2021 (547.7 [496.9 to 586.8] per 100000 people in men and 507 [466.9 to 539.2] per 100000 people in women in 1990) and (378.1 [338.3 to 415.5] per 100000 people in men and 347.5 [305.9 to 381.8] per 100000 people in women in 2021) (Figure S1, S2).

IHD dominates the burden in almost all countries, consistently ranked as the 1st most significant cardiovascular cause of death. Stroke also prominently featured, often ranked 2nd or 3rd in most countries. Atrial Fibrillation and Flutter and Cardiomyopathy and Myocarditis frequently appear in the middle rankings with a decrease in their burden. Hypertensive Heart Disease commonly ranks in the top 5. With a decreasing trend. Following Rheumatic Heart Disease and Non-Rheumatic Valvular Heart Disease Appear sporadically, often with a decreasing trend reflecting improved control and treatment. Aortic Aneurysm and Lower Extremity Peripheral Arterial Disease typically rank lower but show significant increases in some countries like Iran and Libya, suggesting rising health challenges related to these conditions. Endocarditis and Pulmonary Arterial Hypertension varied in presence, often showing increases in some countries like Tunisia and Morocco. (Fig. 3)

Mortality rates increase with age, peaking in the 75–79 years age group. Younger age groups (0–44 years) exhibit significantly lower mortality rates compared to older age groups (45 + years). Males show higher mortality rates in younger age groups (15–44 years) compared to females. (Fig. 3)

From 1990 to 2021, Egypt and Afghanistan showed the highest rate in the age-standardized rate of deaths for CVD which increased from 8633.6 (8235.9 to 9058.7) to 9918.3 (9320 to 10521.4) per 100,000 people. Although Egypt showed a decrease in the rate of death from 798.8 (756.6 to 839.5) in 100,000 people in 1990 to 612.1 (530 to 700.1) in 100,000 people in 2021. (Fig. 2) (Table 1, Table S1, S2).

Some countries have more extended points in particular metrics, indicating higher values. For example, countries like Iraq, Yemen, and Afghanistan show higher values for deaths. Other countries, such as Kuwait and Qatar, display lower values across these metrics, suggesting a lower burden of cardiovascular diseases. (Figure S2, S16-18)

By classifying countries in the NAME region into two clusters based on political stability and conflict history, we have observed the following results:

  1. 1.

    Death Rates: Countries with a history of war or ongoing conflict consistently exhibit higher death rates from 1990 to 2021 compared to those without such a history. While both groups show a general decline in death rates, the gap remains evident.

  2. 2.

    DALYs (Disability-Adjusted Life Years): Countries with a history of war or ongoing conflict report higher DALY rates than those without. Although both groups have experienced a decline over time, the rates remain significantly higher in conflict-affected countries.

  3. 3.

    Incidence Rates: The incidence of diseases is higher in countries with a history of war, particularly in the earlier part of the period (1990–2000). There is a general decrease over time, but the data indicate fluctuations.

  4. 4.

    Prevalence Rates: The prevalence of diseases is initially higher in countries with a history of conflict. After 2010, the gap narrowed, and rates increased in both groups, with a noticeable rise in conflict-affected countries around 2020 (Figure S19, Table S6).

Attributable risk factors

High Systolic Blood Pressure, Dietary Risks, and High LDL Cholesterol are consistently the top three risk factors for both men and women in the NAME region. Smoking, High Body-Mass Index, and Kidney Dysfunction also rank high for both sexes, although smoking tends to be more prevalent among men, while High Body-Mass Index is more prevalent among women. Ambient Particulate Matter Pollution is a significant risk factor in some countries, particularly Egypt and Iran, while Low Physical Activity and Household Air Pollution from Solid Fuels tend to rank lower in terms of impact. (Fig. 5)

However, there are notable differences between the sexes in terms of the prevalence and impact of certain risk factors. For men, Ambient Particulate Matter Pollution and smoking tend to rank higher, while High Body-Mass Index ranks lower compared to women. Kidney Dysfunction and Lead Exposure are generally lower on the list for both sexes, but Household Air Pollution from Solid Fuels tends to be more significant for men in countries like Afghanistan. On the other hand, for women, the High Body-Mass Index tends to rank higher, indicating a critical concern with obesity, while smoking ranks lower relative to other factors. Overall, understanding these gender-specific patterns is crucial in developing targeted interventions to address CVD risk factors in the NAME region. (Fig. 4, Figure S9-13)

Table 1 Age-standardized incidence, prevalence, death, DALY, YLL, and YLD rates of CVD, and their APC from in NAME region, 1991 to 2021. Abbreviations: APC, annual percentage change; DALY, disability-adjusted life years; YLL, years of life lost; YLDs, years lived with disability; CVD, cardiovascular disease; NAME, North Africa and Middle East
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Discussion

Non-communicable diseases are now believed to be the leading causes of morbidity and mortality in low and middle-income countries including the NAME region, and CVD is predicted to become the leading cause of death in this area [25,26,27]. This study aimed to assess the burden of CVD and associated risk factors across the NAME region. The study reveals a consistent pattern in the burden of CVD, with rates of mortality, DALYs, and incidence stabilizing or declining in both males and females. However, the overall age-standardized prevalence rate of CVD showed a slight increase in 2021 compared to 1990. The overall trend suggests that improvements in healthcare and management of CVD have led to lower age-specific rates, despite an increase in total cases likely driven by population growth and aging.

Despite these improvements, sex disparities remain evident. The age-standardized rate of prevalence, incidence, deaths, DALYs, YLLs, and YLDs were all higher in men compared to women in overall CVD burden which is mostly attributable to the protective effects of sex hormones [28]. The rates of high systolic blood pressure, dietary risks, and high LDL cholesterol are critical risk factors affecting both sexes, furthermore, alcohol use and Household air pollution from solid fuels are in the least potent risk factors in both sexes mostly due to religious attitudes [29], yet the prevalence and impact might differ due to sex-specific health behaviors and access to healthcare. Men, particularly in countries like Lebanon, Algeria, and Yemen exhibit higher rates of smoking, a top-five risk factor, which might contribute to higher incidences of IHD and stroke in these populations which is consistent with current literature [30, 31]. Conversely, women may face greater challenges related to high body-mass index and low physical activity, impacting conditions like HHD and diabetes-related cardiovascular complications [32]. Addressing these sex-specific risk factors through targeted interventions is crucial for reducing the CVD burden equitably.

To effectively analyze the trends in CVD morbidity, and mortality across the NAME region, a comprehensive approach is essential. The variability in population distributions among the nations that make up the NAME area is an important issue to take into account. Some nations, like Afghanistan, have become mostly agricultural civilizations with a sizable population residing in rural areas, some countries like Yemen are facing ongoing war, while other nations, like the United Arab Emirates and Qatar, have become industrialized nations.

Ischemic heart disease (IHD) dominated the burden in almost all countries, consistently ranked as the first or second most significant cardiovascular condition, in line with previous global and regional studies [1, 15, 33]. Generally, there was a decrease in IHD burden, indicating improvements in management or prevention. Stroke was also prominently featured, often ranked second across all countries with a consistent decreasing pattern. Hypertensive heart disease (HHD) is commonly ranked in the top five, generally showing a decreasing trend. However, it is noteworthy that diagnosis, sustained management, and preventing of hypertension complications are still major public health challenges [34, 35]. Despite the decreasing global trend of aortic aneurysms, NAME countries exhibit a significant escalating pattern [36]. The Global Burden of Peripheral Artery Disease (PAD) study found that mortality and DALYs rates for PAD follow a U-shaped pattern across income levels with the highest burden in the high and low SDI quintiles [37], which is in line with the increased burden of the disease in NAME region. Furthermore, Endocarditis and pulmonary arterial hypertension (PAH) showed varied presence, often indicating emerging or persistent health issues.

The regional patterns reveal significant progress in reducing the burden of major cardiovascular diseases like IHD and stroke, but persistent or rising issues with conditions like aortic aneurysms and LEPAD in certain areas. For instance, Libya experienced significant increases in aortic aneurysm and LEPAD burden, while Morocco and Tunisia saw noticeable increases in aortic aneurysm and AF/AFL, indicating areas needing focused healthcare interventions. Some countries, such as Iraq, showed higher values for deaths, YLL, and DALYs, highlighting substantial cardiovascular health challenges. Conversely, countries like Kuwait and Qatar displayed lower values across these metrics, suggesting a lower burden of CVD.

Socio-economic factors play a significant role in the burden of CVD across the NAME region. Countries with higher socio-economic status, such as Kuwait and Qatar, display lower values for deaths, YLL, and DALYs, indicating better control or lower incidence of cardiovascular diseases. In contrast, countries like Iraq exhibit higher values for these metrics, reflecting the adverse effects of socio-economic instability on health outcomes. Furthermore, an issue requiring urgent attention is that while the age-standardized DALYs rate due to CVD decreased steadily across all NAME countries, Libya is the exception, experiencing an increase in DALYs rate. Additionally, environmental factors such as ambient particulate matter pollution significantly impact several countries like Egypt and Bahrain, where it is a major concern. Furthermore, previous studies have highlighted the need for comprehensive and urgent public health strategies to reduce these environmental risks in Middle East [38,39,40]. Similarly, high temperatures are increasingly recognized as important environmental risk factors for CVD. Countries like UAE, Qatar, Oman and Iraq had among the highest CVD burden from temperature [41].

Our analysis revealed that in the NAME region, countries with a history of war or ongoing conflict suffer from persistently higher cardiovascular disease burden—evident in mortality, DALYs, prevalence, and also incidence—compared to more stable countries. Although both groups show improvement over time, conflict-affected nations consistently experience greater mortality and disability from cardiovascular diseases. Our results are consistent with a systematic review conducted by Mohammed Jawad et al., indicating higher CVDs and their risk factors in chronic armed conflict situations [42]. These differences most likely result from the complex effects of war: economic difficulties, limited access to healthcare facilities and healthier nutritions, and chronic stress [43].

Comparing our findings with the GBD 2019 study reveals mostly consistent trends [15]. The stabilization or decline in mortality, DALYs, and incidence of CVD in the NAME region is consistent with the trends observed in the GBD 2019 study. Additionally, following the increasing age-standardized prevalence rate between 1990 and 2019, the overall age-standardized prevalence per 100,000 of all CVD cases showed a slight increase from 9816 in 2019 to 9882 in 2021. The 2019–2021 era was accompanied by the COVID-19 pandemic. The healthcare system’s focus shifted towards managing the pandemic, potentially disrupting routine care for chronic conditions, including CVD [44]. Additionally, several articles have suggested different COVID-19-induced cardiovascular complications including thromboembolic, arrhythmogenic, and myocardial complications [45,46,47]. Stress and lifestyle changes induced by lockdowns, such as reduced physical activity and increased dietary risks, might have exacerbated CVD risk factors [48,49,50]. Despite these challenges, the overall decline in CVD burden observed in the study suggests that the healthcare systems in the NAME region have been resilient. However, it is crucial to investigate the long-term impact of COVID-19 on cardiovascular health, particularly considering the potential for increased post-COVID cardiac complications.

Limitation

Despite the comprehensive assessment of CVD burden, our study had some limitations. Since there is currently a dearth of population-level research on the burden of CVD, especially regarding the shifting nature of this burden in nations or with different socioeconomic features, this study could be important for advancing the use of control strategies and enhancing the health care of important populations with CVD. The accuracy and reliability of the findings within the GBD portion of the study rely on the accessibility and quality of available data. Within the NAME region, data sources may be limited, and inconsistencies in data collection methods and variations in data quality among countries can impact the precision of the estimates. Additionally, Standardized disease definitions and classification systems may not align with local disease patterns and healthcare practices. This misalignment can affect the comparability and generalizability of the results. Because it might be difficult to ascertain the actual cause of death, death certificates—despite being essential for public health information—can be incorrectly labeled. Furthermore, the estimates are location- and time-specific, so they might not account for variations among regions or nations or changes over time. Consequently, it’s critical to take these restrictions into account and proceed cautiously when interpreting the study’s findings.

Conclusion

The study highlights significant progress in reducing the burden of cardiovascular diseases in the NAME region, attributed to improved healthcare and management practices. However, persistent sex disparities and socio-economic factors continue to influence CVD outcomes. Comparing the findings with the GBD 2019 study underscores ongoing improvements yet points to emerging challenges that need targeted interventions. Continued efforts are needed to address the specific needs of different populations within the region, focusing on both sex-specific risk factors and socio-economic determinants to achieve equitable health outcomes.

Data availability

The data underlying this article are available at https://vizhub.healthdata.org/gbd-results/.

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Acknowledgements

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Funding

No funding was received for this study.

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Authors and Affiliations

  1. Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, TUMS, Tehran, 1995614331, Iran

    Hamidreza Soleimani, Ali Nasrollahizadeh, Amir Nasrollahizadeh & Kaveh Hosseini

  2. Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

    Ali Nasrollahizadeh

  3. School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Iman Razeghian

  4. School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

    Mohammad Mahdi Molaei

  5. Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Diaa Hakim

  6. Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA

    Khurram Nasir & Sadeer Al-Kindi

Authors
  1. Hamidreza Soleimani
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  2. Ali Nasrollahizadeh
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  3. Amir Nasrollahizadeh
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  9. Kaveh Hosseini
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Contributions

H.S, A.N, A.N and K.H conceived, designed, and planned the study. H.S and K.H acquired and analyzed the data. I.R and MM.M interpreted the results. A.N, A.N, I.R and MM.M drafted the manuscript. D.H, K.N, and S.A contributed to the critical revision of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Ali Nasrollahizadeh.

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Soleimani, H., Nasrollahizadeh, A., Nasrollahizadeh, A. et al. Cardiovascular disease burden in the North Africa and Middle East region: an analysis of the global burden of disease study 1990–2021. BMC Cardiovasc Disord 24, 712 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12872-024-04390-0

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Keywords

BMC Cardiovascular Disorders

ISSN: 1471-2261

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