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Tracy Makuvire, MD, MPH






Brigham and Women's Hospital




*Tracy T Makuvire MD, *Zara Latif MD, *Pankaj Kumar, *Zainab Samad MD, *Haider J Warraich M.D

Principal Investigator

Haider J Warraich M.D


The Global Burden of Ischemic Heart Disease in Females: Data from the 10 Most Populous Low-and Middle-Income Countries

There is a misconception that ischemic heart disease (IHD) mostly affects males in high-income countries. However, about 80% of CVD mortalities predominantly occur in LMICs, and IHD remains a major cause of death globally. Even less is known about the sex burden of IHD in females. Our work explores the trends in IHD in the most populous LMICs and describes trends in mortality rates from IHD among females.

We highlight that the burden of IHD is increasing in LMICs. While the age standardized mortality rate is improving in most countries, the improvement is not consistent across time, and is starting to reverse among females, with a slower decline in many countries than in males. The proportion of deaths amongst females from IHD doubled from 6% in 1990 to 13% in 2019. Sex-specific interventions are needed in LMICs to address the rising prevalence of IHD in females.


Ischemic heart disease (IHD) is a major contributor to mortality in low-and middle-income countries (LMICs). However, the burden of IHD in females in LMICs is not well described.



We analyzed trends in incidence, prevalence, mortality and age-standardized mortality rates (ASMRs) among females from IHD from the ten most-populous LMICs using data from the Global Burden of Disease (GBD) Study from 1990 to 2019. We used Joinpoint Regression Program to analyze trends in mortality and ASMR among females from IHD and permutation tests to estimate the average annual percentage change (AAPC).



In females in the 10 LMICs from 1990 to 2019, IHD incidence increased from 950,000 cases/year to 1.6 million/year, IHD prevalence increased from 8 million to 22.5 million (181% increase) and IHD mortality from 428,320 to 1,040,817 (143% increase). IHD mortality for each country increased with the greatest shift in AAPC seen in the Philippines (5.8%, 95% CI 5.4-6.1) and India (3.7%, 95% CI 3.0-4.4). IHD accounted for 6.2% of all deaths among females in 1990, doubling to 13.2% in 2019. IHD ASMR for females declined in all countries except in Indonesia (AAPC 0.4%), Pakistan (AAPC 0.5%) and the Philippines (AAPC 1.0%). Reductions in ASMR were greater for males than females in Afghanistan, Iran, Egypt, Ethiopia and Nigeria (all p<0.001).



The incidence, prevalence and mortality from IHD among females in LMIC has increased in the 10 most populous LMICs from 1990 to 2019. While the ASMR from IHD across most countries is declining, this was not uniformly noted. Furthermore, several countries noted lesser improvement in ASMR amongst females compared to males. Public policies must acknowledge the increasing burden of IHD among females in LMICs, and target interventions that pursue improving preventive health care, and access to safe food environments among females globally.

Research Context