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

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. Material and methods: Global Burden of Disease (GBD) 2021 examined sex differences in CVD incidence, prevalence, mortality, and disability-adjusted life years (DALYs), including ischemic heart disease, stroke, cardiomyopathy, and others. We evaluated absolute, rate-based, and age-standardized measures, as well as sex-specific risk factor burdens. Results: Age-standardized incidence, prevalence, mortality, and DALY rates of CVD were consistently higher in males compared with females across most CVD types. 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 difference between females and males was observed in age-standardized DALY rates for overall CVD between 1990 and 2021. High systolic blood pressure, dietary risks, and air pollution were major 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 in males. Conclusion: The global burden of CVD is substantially higher in males compared with females, particularly for ischemic heart disease. While primary risk factors are shared, males show a greater burden from tobacco use and elevated LDL cholesterol.