This study reported the ASPR of HHD in WCBA across 204 countries and territories and analyzed its temporal trends, revealing differences in socio-economic levels, regions, and countries. Although the ASPR in high SDI regions declined from 1990 to 2019 (AAPC = -0.52%), there was a significant upward trend in the global ASPR and other SDI regions, especially in low SDI regions.
At the national level, there were significant differences in the ASPR of HHD in WCBA across countries and regions, emphasizing the strong heterogeneity of the global burden of HHD in WCBA. This trend can be attributed to various factors, including genetics (17), exposure to risk factors (18), customs and habits (19), and the prevalence of healthcare systems(20). Wealth or income with its unequal distribution and potentially having significant adverse impacts on health financing, access to healthcare and outcomes (21). Developed countries, relying on well-established healthcare systems, improved diagnosis and treatment rates for HHD (22). However, in many countries with lower socio-economic development, opportunities for primary healthcare are limited, and there is a lack of professional guidelines, medications, and care personnel, leading to lower diagnosis and treatment rates for HHD (23). HHD can interact with other diseases, leading to worse outcomes. Additionally, Most low-income countries continue to have unhealthy food, dense populations, and poor sanitation, which drive up incidence rate of cardiovascular diseases like HHD (24), further explaining the disparities in the burden of HHD.
Additionally, HHD in WCBA shows higher levels in high SDI regions, while it remains lower in other areas, suggesting an intriguing clustering of diseases in relatively developed regions. The high degree of aging in developed countries might also contribute to geographical differences in disease burden (25). In 2014, the United Nations initiated including chronic non-communicable disease control in the Sustainable Development Goals. Countries are dedicating increased resources and funding to HHD, addressing its rapidly rising prevalence and burden (26). Therefore, after 2014, except for a continued increase in the ASPR of HHD in WCBA in low SDI regions, a downward trend in the ASPR was observed in other areas, reducing disparities but still presenting significant challenges. Moreover, over the past two decades, middle and low-income countries have experienced industrialization and globalization, leading to significant lifestyle and dietary changes (27). These changes have substantially contributed to the surge in HHD, primarily driven by metabolic risk factors (28). Given that most HHD in WCBA is preventable through targeting risk factors should continue to focus on interventions and assessments of these factors, especially in regions with limited health resources.
It is well-known that blood pressure in WCBA is slightly lower than in their male counterparts. However, elevated blood pressure on cardiovascular risk differs between men and women (29). Women with hypertension during pregnancy have an increased risk of developing hypertension within one year postpartum and are more likely to develop other cardiac metabolic disorders such as diabetes and hypercholesterolemia (30, 31). An increase of 13 mmHg in systolic blood pressure during pregnancy increases the risk of cardiovascular death by one-fifth (32). Preeclampsia may quadruple the incidence of heart failure and double the incidence of cardiovascular mortality (33). Additionally, compared to older women diagnosed with primary hypertension, hypertension in WCBA is often caused by other conditions or diseases. Major causes include obesity, polycystic ovary syndrome, obstructive sleep apnea, endocrine disorders, kidney disease, and corticosteroid medication use (34). pregnancy-induced preeclampsia, most commonly characterized by the onset of hypertension in mid to late pregnancy, are prevalent, with preeclampsia being a leading cause of preterm birth and ranking third in global maternal mortality causes (35).
Barriers to early prevention include a lack of awareness of cardiovascular disease risk among providers. Increasing training in cardiovascular disease and multicultural competencies might enhance awareness of hypertensive disorders of pregnancy (36). Additionally, raising patient awareness could improve prevention efforts. We recommend educating HHD in WCBA patients about their high risk (37). Encouraging follow-up strategies, including arranging visits at discharge from childbirth, standardized antihypertensive treatment protocols are crucial (38). Telemedicine, including remote home blood pressure monitoring, might also help address gaps in postpartum management of hypertension (39), as this technology has improved blood pressure control in non-pregnant patients.
This study has several limitations. Firstly, due to the imperfect healthcare system, GBD research in underdeveloped countries may result in misdiagnosis and missed diagnosis. Secondly, although GBD collaborators employ efficient data cleansing methods and advanced statistical modeling. However, this may lead to an excessive reliance on modeling data in GBD research. In addition, hypertension is a common risk factor for many diseases. Therefore, patients with HHD often have cardiovascular complications, including ischemic heart disease, heart failure, etc., which may pose a challenge to accurately evaluate HHD. Finally, there is no data available in GBD on trends in various macro and micro social, medical, political, and socio psychological factors, which should be considered in future research.