The following are key points to remember from this state-of-the-art review on the global burden of cardiovascular diseases (CVDs) and risk factors, 1990–2019: update from the GBD 2019 Study:

1. CVD and Disability: Prevalent cases of total CVD nearly doubled from 271 million (95% uncertainty interval [UI], 257-285 million) in 1990 to 523 million (95% UI, 497-550 million) in 2019. The number of CVD deaths steadily increased from 12.1 million (95% UI, 11.4-12.6 million) in 1990, reaching 18.6 million (95% UI, 17.1-19.7 million) in 2019. The global trends for disability-adjusted life-years (DALYs) and years of life lost (YLLs) also increased significantly, and years lived with disability (YLDs) doubled from 17.7 million (95% UI, 12.9-22.5 million) to 34.4 million (95% UI, 24.9-43.6 million) over that period.
2. Ischemic Heart Disease: The total number of DALYs due to ischemic heart disease has risen steadily since 1990, reaching 182 million (95% UI, 170-194 million) DALYs and 9.14 million (95% UI, 8.40-9.74 million) deaths in the year 2019. GBD 2019 estimated 197 million (95% UI, 178-220 million) prevalent cases of ischemic heart disease in 2019.
3. Strokes: The total number of prevalent strokes, deaths, and DALYs due to stroke increased steadily from 1990, reaching 101 million (95% UI, 93.2-111 million) prevalent (85.3% [95% UI, 82.6%-88.2%] increase) stroke survivors, 6.55 million (95% UI, 6.00-7.02 million) deaths from stroke (43.3% [95% UI, 31.0%-55.4%] increase), and 143 million (95% UI, 133-153 million) DALYs due to stroke (32.4% [95% UI, 22.0%-42.2%] increase) in 2019, with the bulk of the burden outside of the high-income world. Of 12.2 million (95% UI, 11.0-13.6 million) incident stroke cases, 7.63 million (95% UI, 6.57-8.96 million) (62.4%) were ischemic stroke, 3.41 million (95% UI, 2.97-3.91 million) (27.9%) were intracerebral hemorrhages, and 1.18 million (95% UI, 1.01-1.39 million) (9.7%) were subarachnoid hemorrhages.
4. Hypertensive Heart Disease: The global prevalence of hypertensive heart disease has risen steadily over the last 3 decades, as have the total number of deaths, DALYs, YLLs, and YLDs due to this disease. In 2019, hypertensive heart disease was the main cause of 1.16 million (95% UI, 0.86-1.28 million) deaths and 21.5 million (95% UI, 16.4-23.9 million) DALYs annually, with a global prevalence of 18.6 million (95% UI, 13.5-24.9 million) cases.
5. Congenital Heart Disease: A total of 3.12 million (95% UI, 2.40-4.11 million) babies were born with congenital heart anomalies in 2019 representing 2,305.2 per 100,000 live births (95% UI, 1,772.9-3,039.2 per 100,000 live births), a total of 13.3 million (95% UI, 11.5-15.4 million) people were living with congenital heart anomalies, and this was the underlying cause of 217,000 deaths (95% UI, 177,000-262,000 deaths), of which 150,000 deaths (95% UI, 120,000-184,000 deaths) were in infants <1 year.
6. Rheumatic Heart Disease: Rheumatic heart disease burden is highest among the world’s disadvantaged populations. Its prevalence has been rising steadily since 1990, reaching 40.5 million (95% UI, 32.1-50.1 million) currently affected in 2019. Deaths decreased until 2012 but have stabilized since then and even started increasing since 2017 (306,000 [95% UI, 259,000-340,000] in 2019).
7. Cardiomyopathy and Myocarditis: The prevalence and related mortality of cardiomyopathy and myocarditis increase throughout adulthood in both sexes with a larger proportion of cases in men than in women. The increased prevalence associated with aging is more pronounced in cardiomyopathies than in myocarditis. DALYs due to cardiomyopathy and myocarditis have increased from 7.06 million (95% UI, 6.30-8.63 million) to 9.14 million (95% UI, 7.86-10.0 million) over the past 30 years, a pattern that is also seen in the rise of deaths from 238,000 (95% UI, 212,000-257,000) to 340,000 (95% UI, 285,000-371,000).
8. Alcoholic Cardiomyopathy: Women are generally considered more susceptible to alcohol-induced damages than men, which may reflect sex-specific differences in alcohol consumption, type, blood level, distribution, or metabolism. However, the higher level of alcohol consumption and the higher frequency of alcohol problems among men could justify the observed higher rate of DALYs. The global prevalence of alcoholic cardiomyopathy estimated by GBD 2019 was 708,000 cases (95% UI, 545,000-924,000 cases), approximately 9.1 cases per 100,000 (95% UI, 7.0-11.9 cases per 100,000). Globally, alcoholic cardiomyopathy was responsible for 71,700 deaths (95% UI, 60,200-82,000 deaths), 2.38 million YLLs (95% UI, 2.00-2.73 million YLLs), and 60,100 YLDs (95% UI, 38,500-88,300 YLDs).
9. Atrial Fibrillation and Atrial Flutter (AF/AFL): The total number of DALYs due to AF/AFL increased progressively from 3.79 million (95% UI, 2.96-4.83 million) in 1990 to 8.39 million (95% UI, 6.69-10.5 million) in 2019. GBD 2019 estimated 59.7 million (95% UI, 45.7-75.3 million) prevalent cases of AF/AFL in 2019, about a doubling compared to the prevalent cases in 1990. Health systems and countries will need to focus their efforts to reverse these trends by aggressive attention to the reduction of risk factors such as hypertension, diabetes, and obesity; better treatment of individuals with IHD and heart failure; and improved access to medications for thromboembolism prophylaxis.
10. Aortic Aneurysm: The total number of YLLs due to aortic aneurysm, including both thoracic and abdominal types, has increased steadily since 1990, reaching 3.32 million YLLs (95% UI, 3.11-3.52 million YLLs) and 172,000 deaths (95% UI, 157,000-183,000 deaths) in 2019.
11. Nonrheumatic Valvular Heart Disease:
    • Calcific aortic valve disease (CAVD): The prevalence of CAVD increases with age and is >1,000 per 100,000 beyond the age of 75 years. Globally, both the prevalence and age-standardized prevalence of CAVD have increased steadily over the last 3 decades. In 2019, the age-standardized prevalence rose to approximately 116.3 cases per 100,000 (95% UI, 100.4-134.5 cases per 100,000) people, from about 45.5 cases per 100,000 (95% UI, 37.6-54.7 cases per 100,000) people in 1990.
    • Degenerative valve disease: The major cause of nonrheumatic degenerative mitral valve disease is mitral valve prolapse. Untreated, this can lead to chronic mitral regurgitation, AF, and heart failure. The total number of DALYs due to degenerative mitral valve disease has increased since 1990 and is responsible for 883,000 DALYs (95% UI, 754,000-1,090,000 DALYs) and 34,200 deaths (95% UI, 28,300-43,300 deaths) in 2019.
12. Endocarditis: The total number of DALYs due to endocarditis has risen steadily since 1990, reaching 1.72 million (95% UI, 1.36-1.94 million) DALYs and 66,300 deaths (95% UI, 46,200-75,900 deaths) in 2019. GBD 2019 estimated 1.09 million (95% UI, 0.913-1.30 million) incident cases of endocarditis in 2019.
13. Peripheral Artery Disease: The global numbers of prevalent cases and deaths due to peripheral artery disease have risen consistently each year since 1990, resulting in a 2-fold increase to 113 million cases (95% UI, 99.2-128 million cases) and 74,100 deaths (95% UI, 41,200-128,000 deaths) in 2019.
14. Modifiable Risk Factors: The impact of risk factors including high systolic blood pressure, high fasting plasma glucose, high low-density lipoprotein cholesterol, impaired kidney function, ambient and household air pollution, tobacco, dietary risks, and low physical activity on GBD is elegantly discussed in this article.
15. The article also discusses the impact of national and subnational data and enumerates strategies to deal with health inequalities and disparities. It also mentions the high rates of excess mortality currently being observed because of the global COVID-19 pandemic, and much of this additional disease burden may be CVD due to the effects of both viral infection but also the unintended consequence of social distancing behaviors, such as changes in the delivery of health care.

Perspective: This outstanding 40-page document is a must-read for all those who strive to reduce the burden of CVD.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Hypertension

Keywords: Aortic Aneurysm, Arrhythmias, Cardiac, Atrial Fibrillation, Atrial Flutter, Cardiomyopathies, COVID-19, Disabled Persons, Endocarditis, Heart Defects, Congenital, Heart Failure, Heart Valve Diseases, Hemorrhage, Healthcare Disparities, Hypertension, Metabolic Syndrome, Mitral Valve Prolapse, Myocardial Ischemia, Myocarditis, Peripheral Arterial Disease, Primary Prevention, Rheumatic Heart Disease, Risk Factors, Stroke, Subarachnoid Hemorrhage, Vascular Diseases

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