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Modifiable Risk Factors and Attributable Ischemic Heart Disease Mortality in US States, 1990-2023
Catherine P. BenzigerBenjamin A. StarkCatherine O. JohnsonGregory A. RothGBD 2023 US IHD CollaboratorsCatherine P. BenzigerBenjamin A. StarkCatherine O. JohnsonShady AbohashemSyed Anees AhmedZiyad Al-AlyMohammed A. AlsabriCatherine M. AntonyAleksandr Y. AravkinDemelash AredaMichelle L. BellMichael BrauerGerald ChiMichael H. CriquiXiaochen DaiOjas Prakashbhai DoshiRajkumar Prakashbhai DoshiAbdel Rahman E’marMuhammed ElhadiLaszlo GöbölösDemewoz HaileJeffrey J. HebertMehdi HemmatiRamzi IbrahimSamuel Berchi KankamRami S. KantarJagdish KhubchandaniMin Seo KimRuth W. KimokotiAdnan KisaMichail KokkorakisAshish KumarXuefeng LiuLei LvMorteza MahmoudiYosef ManlaRamon Martinez-PiedraSammer MarzoukGeorge A. MensahTomislav MestrovicTed R. MillerAli H. MokdadVincent MouginAhmad MustafaMahmoud NassarZuhair S. NattoFred NugenRomil R. ParikhMaja PasovicShankargouda PatilJagadeesh PuvvulaShakthi Kumaran RamasamyAhmed Mustafa RashidKevin T. RootMonika SawhneyArt SchuermansMariam ShariffKerem ShuvalGizeaddis Lamesgin SimegnRohit SinghLauryn K. StaffordJabeen TaibaManoj TanwarMasayuki TeramotoSathish ThirunavukkarasuThang Huu TranDipan UppalManish VinayakDeniz YuceChristopher J. L. MurrayAndrew E. MoranGregory A. Roth
Key result
Modifiable risk factors account for ~89% of IHD deaths, led by high SBP, diet, and LDL-C.
- or 88.7
Why the study?
Ischemic heart disease is the leading cause of death in the US and predominantly driven by modifiable risk factors, making updated attributable mortality estimates essential for health policy decisions.
Key Points
- This analysis aims to quantify the burden of ischemic heart disease (IHD) mortality attributable to modifiable risk factors in the US over the period from 1990 to 2023.
- Employing the Global Burden of Disease Study 2023 (GBD 2023) framework to analyze epidemiological data from vital records and other sources.
- Used ensemble modeling methods to estimate IHD death rates per 100,000 persons and applied bayesian meta-regression methods for risk factor exposure analysis.
- Estimated relative risks based on a recognized Burden of Proof framework.
- In 2023, there were approximately 473,000 IHD deaths in the US, marking a decrease of 58.7% in age-standardized rates since 1990.
- High systolic blood pressure, dietary risks, and high LDL cholesterol collectively accounted for nearly 47.2%, 38.6%, and 28.5% of IHD deaths, respectively.
- Smoking and particulate matter pollution showed substantial decreases in attributable mortality since 1990, at 33.3% and 74.9%, respectively.
Study Design
Type
Observational
Multicenter
Yes
Structured PICO
P
Population
General population of the US from 1990-2023 assessed for ischemic heart disease mortality attributable to 12 metabolic, behavioral, and environmental risk factors.
E
Exposure
Exposure to twelve metabolic, behavioral, and environmental risk factors
O
Outcome
Ischemic heart disease (IHD) death rates per 100,000 persons, counts, and attributable risks from 1990-2023 by age, sex, and US statehard clinical
Ask about this paper
Answers are grounded in this paper and cite their sources.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Reductions in IHD mortality in the US have slowed, especially in younger populations. Past declines in IHD mortality in the US are unlikely to resume without further reduction of these leading risk factors.”
“This is a great example of how smart health policies can benefit everyone. It isn't as much a surprise as a reminder that improving cardiovascular health can start with policies that are good for everyone. With increasing wildfire smoke events and major cuts to federal efforts to keep air clean, we need to make sure we don't lose ground on clean air.”
DRDr. Robert M. CaliffCardiologist and Former FDA Commissioner
“It is ironic that a society with such a surplus of resources is not aggressively addressing this issue when it is overwhelmingly likely that a combination of policy interventions, attention to reliable communication about health in our information ecosystem, and wider use of generic medicines would dramatically reduce the scourge of CKM syndrome.”
Implication
Nearly 90% of ischemic heart disease deaths in the US are attributable to modifiable risk factors, emphasizing the critical need for population-level interventions targeting blood pressure, diet, and cholesterol.
Abstract
Importance: Ischemic heart disease (IHD), the leading cause of death in the US, is predominantly due to modifiable risk factors. Estimates of IHD mortality attributable to risk factors provide evidence for health policy decision-making. Objective: To estimate the burden of IHD death attributable to risk factors in the US from 1990-2023. Design, Setting, and Participants: The Global Burden of Disease Study 2023 (GBD 2023) used vital records and a broad set of epidemiologic data to estimate IHD death rates, risk factor exposure, and relative risk curves for risk-outcome pairs for 1990-2023 for the general population. Data analysis was performed from October 2024 to December 2025. Exposure: Twelve metabolic, behavioral, and environmental risk factors. Main Outcomes and Measures: The primary outcomes were IHD death rates per 100 000 persons, counts, and attributable risks from 1990-2023 by age, sex, and US state. Estimates include 95% uncertainty intervals (UI). IHD death rates were estimated using ensemble modeling methods. Risk exposures were estimated using bayesian meta-regression methods. Relative risks were estimated following the Burden of Proof framework. Results: In 2023, there were 473 000 IHD deaths (95% UI, 414 000-510 000) in the US, a decrease of 58.7% (95% UI, 56.8%-61.0%) in age-standardized rate since 1990. Between 2010 and 2023, there was a 19.0% decrease (95% UI, 15.0%-22.9%) for males and a 24.5% decrease (95% UI, 20.3%-29.7%) for females in IHD death rates. High systolic blood pressure (SBP), dietary risks, and high low-density lipoprotein cholesterol (LDL-C) were the leading risk factors for IHD deaths in 2023, accounting for 47.2% (95% UI, 36.4%-57.0%), 38.6% (95% UI, 17.2%-56.8%), and 28.5% (95% UI, 19.3%-39.6%) of IHD deaths, respectively. Increased exposure to several risk factors substantially increased their attributable burden for IHD deaths in 2023, with high fasting plasma glucose (FPG) increasing 38.8% (95% UI, 11.5%-81.1%) and high body mass index (BMI) increasing 54.5% (95% UI, 41.8%-66.3%) since 1990. Smoking and particulate matter pollution had the greatest decrease in attributable IHD mortality since 1990, at 33.3% (95% UI, 23.6%-41.7%) and 74.9% (95% UI, 46.7%-88.8%), respectively. Conclusion and Relevance: Per the results of this systematic analysis of GBD 2023, a total of 88.7% (95% UI, 83.4%-92.5%) of IHD deaths were attributable to modifiable risk factors in the US in 2023, with high SBP, dietary risks, and high LDL-C being the greatest contributors. High BMI and high FPG showed the largest attribution increases, while exposure to other risks did not increase significantly for the population.
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
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Cite This Study
Benziger et al. (2026) conducted an observational in Ischemic heart disease. Modifiable risk factors was evaluated on IHD death rates per 100 000 persons, counts, and attributable risks from 1990-2023 by age, sex, and US state. Modifiable risk factors accounted for 88.7% (95% UI 83.4-92.5%) of US ischemic heart disease deaths in 2023, led by high systolic blood pressure, dietary risks, and high LDL-C.