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Abstract
Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally yet remains under-recognized and under-researched in women. Despite increasing emphasis on sex and gender influences in CVD, there is limited and conflicting evidence on sex differences in the burden and risk factors of CVD worldwide. We aimed to assess sex differences in the global burden of CVD and its attributable risk factors from 1990 to 2021.
Methods: We used data from the Global Burden of Disease (GBD) 2021 study, covering 204 countries and territories, to evaluate sex differences in incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of CVDs, including ischemic heart disease, stroke, cardiomyopathy, and others. Analyses were conducted in terms of absolute numbers, rates, and age-standardized rates. We also assessed sex differences in CVD burden attributable to risk factors using a comparative risk assessment framework.
Findings: Age-standardized incidence, prevalence, mortality, and DALY rates of CVD were consistently higher in males compared with females across most CVD types. Among specific CVDs, ischemic heart disease showed the largest disparities, with males having higher incidence (147.9 [95% uncertainty interval 57.7 to 244.6] per 100 000), prevalence (1253.6 [633.1 to 1816.6] per 100 000), mortality (51.0 [38.3 to 63.1] per 100 000), and DALY rates (1286.2 [1069.9 to 1511.7] per 100 000) compared to females. In contrast, females had higher incidence (55.9 [33.9 to 79.6] per 100 000) and prevalence rates (699.5 [415.5 to 983.5] per 100 000) compared to males in lower extremity peripheral arterial disease. A stable absolute difference between females and males was observed in age-standardized DALY rates for overall cardiovascular disease between 1990 and 2021. High systolic blood pressure, dietary risks, and air pollution were the leading contributors to CVD-related DALYs for both sexes, although tobacco use (144.0 million DALYs for males vs. 31.5 million for females), elevated LDL cholesterol (130.1 million DALYs for males vs. 75.9 million for females), and impaired kidney function (59.8 million DALYs for males vs. 39.3 million for females) were disproportionately higher risk factors for males.
Interpretation: The global burden of CVD is substantially higher in males compared with females, particularly for ischemic heart disease. While the primary risk factors are shared between sexes, males show a greater burden attributable to tobacco use and elevated LDL cholesterol. These findings highlight the importance of sex-specific approaches in CVD prevention and management, with particular emphasis on reducing modifiable risk factors in both sexes and addressing disparities across socio-demographic index levels.
Funding: Research reported in this publication was funded by the Bill & Melinda Gates Foundation.
Declaration of Interest: We declare no competing interests.
Fan, Jiaqi and Chen, Jun and Wang, Litao and Yuan, Changzheng and Liu, Xianbao and Wang, Jian’an, The Global Burden and Attributable Risk Factor Analysis of Cardiovascular Disease between Females and Males, 1990-2021: Findings from the 2021 Global Burden of Disease Study. Available at SSRN:
https://ssrn.com/abstract=5048719 or
http://dx.doi.org/10.2139/ssrn.5048719
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