In Pakistan, women with IHD had higher mortality risk (4.4% vs. 3.1% in men, 2021) linked to high systolic BP and low vegetable and fiber intake.
Are there sex-based differences in ischemic heart disease mortality and prevalence in South Asia?
In South Asia, sex disparities in ischemic heart disease mortality are most prominent in Pakistan, where women face a higher excess mortality risk driven by high systolic blood pressure and poor dietary habits.
Abstract Background South Asia bears the highest global burden of ischaemic heart disease (IHD). This study aimed to assess variations in IHD mortality, prevalence, and risk factors by sex across South Asia to identify key determinants of excess mortality in women. Examining outcome variations by sex, income level, and country within this region could guide effective public health policies. Purpose To examine sex-based differences in IHD outcomes and their association with metabolic and dietary risk factors in South Asia using data from the Global Burden of Disease (GBD) 2021 study. Methods Cross-sectional analyses of the GBD Study, IHD and cardiovascular risk factor data for years 2005 and 2021 estimating sex-specific age-standardized IHD mortality rate (ASMR) and age-standardized IHD prevalence rate (ASPR) ratio (ASMR-to-ASPR index) per 100,000 inhabitants/year across five countries in South Asia (Bangladesh, Bhutan, India, Nepal, and Pakistan). The ASMR-to-ASPR index quantifies the excess mortality risk among affected individuals. A ratio of 1.0 indicates equal risk between sexes, values greater than 1.0 denote a relatively elevated risk in women, and values below 1.0 indicate a relatively lower risk in women, . Women-to-women and men-to-men comparisons across countries were conducted using Z-scores, with values greater than 1.96 or less than -1.96 deemed statistically significant at the 95% confidence level. Results Across all countries, the age-standardized mortality rate (ASMR) was consistently higher in men than in women. In 2005, the mean ASMR was 167 per 100,000 inhabitants for men compared to 102 per 100,000 for women; by 2021, these values had increased to 190 per 100,000 in men and 112 per 100,000 in women. The ASMR-to-ASPR index was significantly higher in women than men only in Pakistan, both in 2005 (4.3% vs. 2.9%) and 2021 (4.4% vs. 3.1%), indicating a higher risk of death among Pakistani women with IHD. A Z-score analysis comparing Bhutan (lowest ASMR for women) and Pakistan (highest ASMR for women) revealed significant differences in mortality attributable to high systolic blood pressure (Z-score: 3.30), low vegetable intake (Z-score: 2.02), and low fiber intake (Z-score: 2.00). These disparities were not observed in men. Conclusion Mortality among people with IHD remains high across South Asia, with sex disparities in outcomes observed primarily in Pakistan. Leading risk factors for IHD mortality among women include high systolic blood pressure and low intake of vegetables and fiber. Although blood pressure screening and affordable antihypertensive medications are increasingly available, reducing excess IHD mortality in women requires a stronger emphasis on prevention. Promoting a diet rich in vegetables and fiber, both within South Asia and among migrant populations, could help mitigate sex-based inequities in IHD mortality.
Rahaman et al. (2025) studied this question. In Pakistan, women with IHD had higher mortality risk (4.4% vs. 3.1% in men, 2021) linked to high systolic BP and low vegetable and fiber intake.