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Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality
Open accessAbstract
BACKGROUND: Global deaths from cardiovascular disease are increasing as a result of population growth, the aging of populations, and epidemiologic changes in disease. Disentangling the effects of these three drivers on trends in mortality is important for planning the future of the health care system and benchmarking progress toward the reduction of cardiovascular disease. METHODS: We used mortality data from the Global Burden of Disease Study 2013, which includes data on 188 countries grouped into 21 world regions. We developed three counterfactual scenarios to represent the principal drivers of change in cardiovascular deaths (population growth alone, population growth and aging, and epidemiologic changes in disease) from 1990 to 2013. Secular trends and correlations with changes in national income were examined. RESULTS: Global deaths from cardiovascular disease increased by 41% between 1990 and 2013 despite a 39% decrease in age-specific death rates; this increase was driven by a 55% increase in mortality due to the aging of populations and a 25% increase due to population growth. The relative contributions of these drivers varied by region; only in Central Europe and Western Europe did the annual number of deaths from cardiovascular disease actually decline. Change in gross domestic product per capita was correlated with change in age-specific death rates only among upper-middle income countries, and this correlation was weak; there was no significant correlation elsewhere. CONCLUSIONS: The aging and growth of the population resulted in an increase in global cardiovascular deaths between 1990 and 2013, despite a decrease in age-specific death rates in most regions. Only Central and Western Europe had gains in cardiovascular health that were sufficient to offset these demographic forces. (Funded by the Bill and Melinda Gates Foundation and others.).
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“For the most common cause of cardiovascular death, ischemic heart disease, the number of deaths increased by an estimated 41.7% from 1990 to 2013.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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“Even larger declines (more than 55%) were seen as a result of epidemiologic changes in the risk of hemorrhagic stroke.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES
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“According to our estimates, epidemiologic change led to an increase in cardiovascular deaths in only one region of the world (western sub-Saharan Africa).”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > CARDIOVASCULAR DEATHS ACCORDING TO REGION
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“The combination of increases in the number of deaths due to population growth and population aging and declines in age-specific death rates represented the most common epidemiologic profile among the specific cardiovascular causes of death (Table 1).”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES
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“whereas population growth contributed to an estimated 23.6% increase.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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“Rheumatic heart disease was the only cardiovascular condition for which there were fewer total deaths globally in 2013 than in 1990.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES
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“Ischemic heart disease was the largest contributor to the increase in the number of cardiovascular deaths (2.4 million of the overall increase of 5.0 million cardiovascular deaths)”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES
Strength:plain· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
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“Central Europe and Western Europe, which had declines of an estimated 5.2% and 12.8%, respectively.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > CARDIOVASCULAR DEATHS ACCORDING TO REGION
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“East Asia reported more than 1.2 million additional deaths in 2013, representing a 47.2% increase from 1990.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > CARDIOVASCULAR DEATHS ACCORDING TO REGION
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“only in Central Europe and Western Europe did the annual number of deaths from cardiovascular disease actually decline.”
- Also stated in: § CARDIOVASCULAR DEATHS ACCORDING TO REGION · plain
“The only regions with a significant decrease in cardiovascular deaths were Central Europe and Western Europe, which had declines of an estimated 5.2% and 12.8%, respectively.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > Abstract > RESULTS
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § CARDIOVASCULAR DEATHS ACCORDING TO REGION · plain
- It may state two separate claims as one. 10
- The quote only partly states this claim. 1
- Probably not a substantial claim. 8
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“Change in gross domestic product per capita was correlated with change in age-specific death rates only among upper-middle income countries, and this correlation was weak; there was no significant correlation elsewhere.”
- Also stated in: § CARDIOVASCULAR DEATHS AND NATIONAL INCOME PER CAPITA · plain
“the two variables had a significant correlation only within the category of upper-middle income.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > Abstract > RESULTS
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- Also stated in: § CARDIOVASCULAR DEATHS AND NATIONAL INCOME PER CAPITA · plain
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“Southern Latin America, Australasia, and high-income North America had no detectable change in the number of deaths from 1990 to 2013 (as indicated by an uncertainty interval crossing 0) because population aging and growth balanced out declines in age-specific death rates.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > CARDIOVASCULAR DEATHS ACCORDING TO REGION
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“Atrial fibrillation or flutter and peripheral vascular disease are notable exceptions to the demographic and epidemiologic pattern for cardiovascular disease. Deaths from each of these conditions increased dramatically between 1990 and 2013, driven not only by population growth and aging but also by increases in age- and sex-specific death rates.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES
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“In absolute terms, South Asia had the largest estimated increase in deaths from cardiovascular disease, reporting more than 1.7 million more deaths in 2013 than in 1990. This change represents an increase of 97.4% (95% uncertainty interval, 72 to 126.1).”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > CARDIOVASCULAR DEATHS ACCORDING TO REGION
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“For example, there were 349,153 cardiovascular deaths in the high-income Asia–Pacific region in 1990. In 2013, there were 487,170 cardiovascular deaths, which is less than the 910,042 that would have been expected if 1990 death rates had remained constant, given the population size and the age structure in that region in 2013.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > METHODS > DETERMINATION OF DRIVERS OF CARDIOVASCULAR MORTALITY
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“Most countries had an increase in income per capita and a decline in the number of cardiovascular deaths due to epidemiologic change.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > CARDIOVASCULAR DEATHS AND NATIONAL INCOME PER CAPITA
Strength:plain· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
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“despite a 39% decrease in age-specific death rates”
- Also stated in: § GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES · plain
“despite a decrease in deaths attributable to epidemiologic changes of 39.3% (95% uncertainty interval, 33.6 to 44.1)”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > Abstract > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesThe quote only partly states this claim.
- Also stated in: § GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES · plain
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“This pattern was also present in trends for ischemic heart disease, ischemic stroke, hemorrhagic and other nonischemic causes of stroke, hypertensive heart disease, cardiomyopathy, myocarditis, aortic aneurysm, and endocarditis.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > RESULTS > GLOBAL DEATHS DUE TO CARDIOVASCULAR DISEASES
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
In the paper
“These changes are probably due to the combined effect of birth cohorts’ decreased exposure to tobacco smoking, improvements in diet, and improved treatment of cardiovascular disease and cardio-metabolic risk factors targeting the prevention of cardiovascular disease, and improved treatment of cardiovascular disease.10”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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- Not checked yetcites [10] source
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“In contrast, South Asia had a dramatic rise in cardiovascular deaths due to population growth and aging without a significant decline in cardiovascular deaths due to epidemiologic change.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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“However, the rigorous out-of-sample predictive validity testing used in GBD 2013 is cause for some confidence.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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In the paper
“As they have noted, the classic model of “epidemiologic transition” does not fully reflect the heterogeneity of the burden of cardiovascular disease across countries.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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“A deterministic health policy model indicated that 40 to 55% of the decline in coronary heart disease in high-income countries can be attributed to the effects of medical and surgical treatments.12”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
What the sources say
- Not checked yetcites [12] source
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In the paper
“Finally, we recognize that patterns of disease burden vary not just between but also within countries. Any summary provided at the level of a region or country may mask significant disparities within that area.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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In the paper
“However, calculations made with the traditional Shapley method and other methods used in econometrics may produce different results.6”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
What the sources say
- Not checked yetcites [6] source
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“First, cause-specific mortality data are lacking or of limited quality in some countries.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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“Similarly, the number of deaths resulting from rheumatic heart disease may not be completely captured by vital records in regions in which the condition is endemic.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
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In the paper
“Furthermore, the remarkable increase in the age-specific rate of death from atrial fibrillation probably reflects increases in the screening, recognition, and attribution of death to atrial fibrillation in addition to changes in disease epidemiology.”
§ Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality > DISCUSSION
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✗ Based: failsProbably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
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“Ageing of the population also contributes to increasing the absolute number of CVD events. 17”
From 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias (2016) · cites this paper as [17]
In the citing paper
“Ageing of the population also contributes to increasing the absolute number of CVD events.17”
From 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias (2016) · cites this paper as [17]
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Metadata
- Authors
- Roth, G. A., Forouzanfar, M. H., Moran, A. E., Barber, R., Nguyen, G., Feigin, V. L., Naghavi, M., Mensah, G. A., & Murray, C. J. L.
- Affiliations
- National Institutes of Health (US)
- University of Washington (US)
- Columbia University (US)
- Auckland University of Technology (NZ)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2015-04-02
- Volume
- 372
- Issue
- 14
- Pages
- 1333-1341
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC4482354
- OpenAlex
- W1986019364
- Semantic Scholar
- 27a6b9a739f391969318dbfd3ffe6b84aa566d21
- Cited by
- 1,188
- References
- 14
- Citations by year
- 2026: 30 · 2025: 87 · 2024: 115 · 2023: 110 · 2022: 117 · 2021: 123 · 2020: 141 · 2019: 118 · 2018: 105 · 2017: 110 · 2016: 98 · 2015: 31
- FWCI
- 89.97
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (K08HL089675)
- Topics
- Health Sciences › Medicine › Epidemiology › Healthcare Systems and Public Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Social Sciences › Demography › Insurance, Mortality, Demography, Risk Management
- Keywords
- cardiovascular mortality, population aging, population growth, age-specific mortality, counterfactual scenarios, GDP per capita, global health trends, regional variation in mortality
- MeSH terms
- Age Factors, Cardiovascular Diseases, Demography, Humans, Income, Mortality, Sex Factors, Global Health
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