Three decades of ischemic heart disease–related heart failure in G20 countries: shifting burden, inequalities, and projections to 2050

The aim of this study was to characterize the burden of ischemic heart disease (IHD)-related heart failure (HF) in Group of 20 (G20) countries. Using Global Burden of Disease (GBD) 1990–2021 data, we assessed prevalence and years lived with disability (YLDs) for IHD-related HF. Overall, the total number of prevalent cases in the G20 countries increased substantially from 6.18 million in 1990 to 14.82 million in 2021, accompanied by a slight increase in the Age-Standardized Prevalence Rate (ASPR) from 222.51 to 229.45 per 100,000 population. Total YLD cases expanded from 0.56 million to 1.33 million, with the Age-Standardized YLD Rate (ASYR) exhibiting a marginal elevation from 19.94 to 20.54 per 100,000 individuals (EAPC = 0.12, 95% CI: 0.07 to 0.17). Regional heterogeneity was substantial: China witnessed a striking rise in absolute prevalence from 1.01 million to 4.59 million cases, with its ASPR increasing from 146.54 to 230.21 per 100,000. In contrast, while the United States and Russia experienced increases in absolute cases, both demonstrated declining trends in their ASPRs. Age and sex specific analyses revealed that male populations consistently bore a higher burden in both prevalence and YLDs. Furthermore, socio-demographic inequality (SDI) analyses revealed that the burden of IHD-related HF was increasingly concentrated in higher-SDI settings, with the Concentration Index (CI) transitioning from negative to positive values between 1990 and 2021. Long-term Bayesian age-period-cohort (BAPC) projections forecast that the total number of prevalent cases across G20 nations will sustain an upward trajectory by 2050. The absolute and age-standardized burdens of IHD-related HF across G20 countries have expanded significantly over the past three decades, exhibiting profound regional heterogeneity and remaining heavily concentrated in males and individuals aged over 75. Critically, our inequality and long-term projection data demonstrate that this chronic disease reservoir is shifting toward higher-SDI sectors and will continue to swell through 2050. These findings underscore that a generic public health strategy is no longer sufficient; instead, G20 health systems must implement tiered, stratified interventions that transition from focusing solely on acute revascularization survival to establishing robust, chronic heart failure management networks.