Sociodemographic and sex differences in the global burden of hypertensive heart disease, 1990–2021: a population-based analysis

BACKGROUND: Hypertensive heart disease (HHD) is a major global contributor to cardiovascular-related disability. Although its burden has been previously described, detailed analyses of long-term disability trends by sociodemographic level and sex remain scarce. This study aimed to systematically assess global and subgroup-specific patterns in HHD-related disability-adjusted life years (DALYs) from 1990 to 2021. METHODS: Data from the Global Burden of Disease Study 2021 were used to evaluate age-standardized DALY rates for HHD across five socio-demographic index (SDI) levels and by sex from 1990 to 2021. Temporal trends were assessed using Joinpoint regression with estimated annual percent change (EAPC). Future rates through 2036 were projected using Bayesian age-period-cohort models. Decomposition analysis quantified contributions of population growth, aging, and epidemiologic changes, and risk-attributable DALYs were estimated for five modifiable exposures. RESULTS: Globally, DALYs from HHD increased from 15.47 to 25.46 million (+ 64.6%) between 1990 and 2021, while the age-standardized DALY rate declined from 406.51 to 301.58 per 100,000 population (EAPC - 0.96; 95% CI - 0.98 to - 0.93). DALY counts rose and age-standardized DALY rate declined across all SDI levels, with the greatest reduction in middle-SDI regions (EAPC - 1.89; 95% CI - 2.17 to - 1.60) and notable decreases in high-middle SDI regions (EAPC - 1.06; 95% CI -1.68 to - 0.43). Rates in females remained consistently higher than in males, with projections suggesting persistent disparities through 2036. Decomposition analysis indicated that population aging and growth were the main contributors to DALY increases, partially offset by epidemiological improvements. High systolic blood pressure (- 100%) and elevated body mass index (- 50%) were the leading modifiable risk factors across SDI levels. CONCLUSIONS: Despite declines in age-standardized DALY rate, the absolute HHD burden continues to grow, particularly among women and in low-SDI regions. Targeted, equity-focused cardiovascular strategies are urgently needed to address these persistent disparities.