(2024) 22:303
Li et al. BMC Medicine
https://doi.org/10.1186/s12916-024-03527-4

BMC Medicine

RESEARCH ARTICLE

Open AccessComparative analysis of atherosclerotic
cardiovascular disease burden between ages
20–54 and over 55 years: insightsfrom the Global Burden of Disease Study 2019
Ziyi Li1,2, Yucheng Yang1,2, Xuechen Wang1,2, Na Yang1,2, Liyun He1,2, Jialu Wang1,2, Fan Ping1,2, Lingling Xu1,2,
Huabing Zhang1,2* , Wei Li1,2*   and Yuxiu Li1,2*   

Abstract
Background To systematically analyze differences in atherosclerotic cardiovascular disease (ASCVD) burden
between young and older adults.
Methods We estimated the prevalence, mortality, and disability-adjusted life years (DALYs) of ASCVD, including ischemic heart disease (IHD), ischemic stroke (IS), and peripheral artery disease (PAD), in individuals aged 20–54
and > 55 years from 1990–2019, utilizing data from the 2019 Global Burden of Disease Study. The annual percentagechanges (EAPCs) for age-specific prevalence, mortality, or DALY rates were calculated to quantify the temporal trendsof ASCVD burden. We also analyzed population attribution fractions (PAF) of premature ASCVD mortality and DALYs
for different risk factors and compared the burden of extremely premature, premature, and non-premature ASCVD
cases based on clinical classifications.
Results From 1990–2019, the global prevalence rates of IHD, IS, and PAD in the 20–54 years age group increased
by 20.55% (from 694.74 to 837.49 per 100,000 population), 11.50% (from 439.48 to 490.03 per 100,000 population), and 7.38% (from 384.24 to 412.59 per 100,000 population), respectively. Conversely, the ASCVD prevalence in > 55years age group decreased. Adverse outcome burdens, including mortality and DALYs, variedamong ASCVD subtypes. The decrease in the mortality/DALY burden of IHD and IS was lower in the 20–54 years
group than in the > 55 years group. For PAD, DALYs among those aged 20–54 increased but decreased among those
aged > 55 years. When grouped according to socio-demographic index (SDI) values, lower SDI regions exhibiteda higher proportion of young ASCVD burden. The prevalence of young IHD, IS, and PAD in low SDI regions reached20.70%, 40.05%, and 19.31% in 2019, respectively, compared with 12.14%, 16.32%, and 9.54%, respectively, in high SDI
regions. Metabolic risks were the primary contributors to the ASCVD burden in both age groups. Increased susceptibility to ambient particulate matter pollution and inadequate control of high body-mass index and high fasting*Correspondence:
Huabing Zhang
huabingzhangchn@163.com
Wei Li
weili0021@aliyun.com
Yuxiu Liliyuxiu@medmail.com.cn
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Li et al. BMC Medicine(2024) 22:303

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plasma glucose in young individuals may partially explain the differing temporal trends between young and older
individuals.
Conclusions The ASCVD burden in young individuals may become a growing global health concern, especiallyin areas with lower socioeconomic development levels that require more effective primary prevention strategies.
Keywords Premature atherosclerotic cardiovascular disease, Extremely premature atherosclerotic cardiovasculardisease, Ischemic heart disease, Ischemic stroke, Peripheral artery disease, Global disease burden

Background
Atherosclerotic cardiovascular diseases (ASCVDs),
including ischemic heart disease (IHD), ischemic stroke(IS), and peripheral arterial disease (PAD), are the mostcommon cardiovascular diseases [1]. While previous
studies have reported the global burden and trends ofcardiovascular diseases (CVDs) from 1990–2019 [2, 3],
the specific global disease burden of ASCVDs, distinguished by the unique pathogenesis of CVD and theirstatus as the leading cause of global mortality and disability, remains incompletely documented.
Although the majority of the ASCVD burden occurs inolder individuals, the risk of ASCVD in young individuals
is increasing [4]. Studies indicate that atherosclerosis canbegin early in life, and subclinical atherosclerosis in youth
significantly increases the risk of subsequent all-cause
mortality [5, 6]. Estimates suggest that the prevalence of
ASCVD in young adults ranges from 7 to 30%, depending
on different age groups, subtypes of ASCVD, and geographic regions [7–10]. Owing to the relatively young age
at the time of diagnosis, ASCVD in younger age groups
impose a great financial burden on the healthcare system.
No study has precisely quantified the proportion of thetotal ASCVD burden attributable to young individuals.
Focusing on risk factors is crucial to reduce the burdenof ASCVD. Previous research has suggested that > 90% of
the population-attributable risk of myocardial infarction
can be attributed to traditional cardiovascular risk factors[11]. Since the World Health Organization establisheda target for preventable risk factors to reduce ASCVD
mortality by 25% from the 2010 levels by 2025 [12], incidence and mortality rates of ASCVD have declined [13].
However, a similar decline has not been observed amongindividuals with early-onset ASCVD [14]. Consequently,
uncertainty persists regarding whether the disparity
between age groups stems from varying changes in risk
factors. Additionally, identifying age-specific ASCVD
risk factors is vital for devising tailored intervention
strategies.
To address this knowledge gap, our objective was tocompare the burden of ASCVD between younger andolder populations. This entails elucidating the global
epidemiological characteristics of ASCVD burden
in individuals aged 20–54 years and those > 55 years.

Furthermore, we compared the burden associated withextremely premature, premature, and non-premature
ASCVD, as defined by clinical classifications. This investigation included a comparison of disease burden trends
across various ASCVD subcategories. To inform targeted public health strategies, we aimed to identify anddescribe the risk factors contributing to both demographic groups.
Methods
Overview of the data sources

The 2019 Global Burden of Disease Study (GBD) estimated the disease burden of various disorders across204 countries and territories [15]. Data were collected
through systematic assessment of censuses, household
surveys, civil registrations, vital statistics, disease registries, and other methods. Mortality data were analyzed
using the Cause of Death Ensemble model (CODEm)
to assess the death toll as accurately as possible.[16],whereas disability-adjusted life years (DALYs) were
estimated using the DisMod-MR 2.1 a Bayesian metaregression tool [17]. The world was divided into 21
super-regions based on epidemiological similarities andgeographical proximity to analyze the disease burden
across locations [18]. Meanwhile, socio-demographic
index (SDI) was utilized to classify the countries and territories [19].
Estimation of ASCVD disease burden in young and older
individuals

As IHD, IS, and PAD represent the primary componentsof ASCVD, the annual data for these three ASCVD subtypes were analyzed separately. According to the age
ranges provided by the 2019 GBD database, we defined
young group (age 20–54 years) and old group (age > 55
years). In addition, to further clarify the burden of
ASCVD in different age groups, we further defined
extremely premature ASCVD (age < 40 years), premature ASCVD (age < 55 years in males; age < 65 years infemales), and non-premature ASCVD (age ≥ 55 years inmales; age ≥ 65 years in females). New age group data
were synthesized by multiplying the crude rates of each5-year age group by the proportion of that group’s population under the standard population provided by theLi et al. BMC Medicine(2024) 22:303

GBD database [18]. We obtained data on the prevalence,
DALYs, and mortality rates of IHD, IS, and PAD according to sex and region from the 2019 GBD study. Relevant
data were retrieved from the following website (https://​vizhub.​healt​hdat.​org/​gbd-​resul​ts/).
Estimation of attributable risk factors for ASCVD

Metabolic, behavioral, and environmental factors contribute to the risk of ASCVD. A total of 27 subcategories of risk factors were related to ASCVD in the 2019
GBD study. Under the GBD framework, there is a theoretical minimum exposure level (TMREL) at which therisk to health outcomes are lowest. The risk factors anddefinitions are provided in the Appendix (Additional
file 1:Table S1).
Statistical analysis

Descriptive analysis characterized the ASCVD burden,
comparing the prevalence, mortality, and DALY rates in1990 and 2019, both in terms of the number of cases andrates per 100,000 population. The estimated annual percentage change (EAPC), calculated using a generalized
linear model with a Gaussian distribution to describe
the age-specific rate (ASR) trend over time, was used
to quantify the trends of this burden [19, 20]. We also
explored the ASCVD burden across 204 countries andterritories of the world. The relationships between therates and SDI were evaluated using Pearson’s correlation.
Population attribution fractions (PAFs) of ASCVD deaths
and DALYs for different risk factors were analyzed. The
95% confidence interval (CI) based on 1000 draws fromthe posterior distribution of each step in the estimation
process were calculated using the 2.5th and 97.5th percentiles of the ordered 1000 values.
Data analysis and illustrations were performed using R
software version 4.0.2, and p-values < 0.05 were considered statistically significant.

Results
ASCVD burden among individuals aged 20–54 years

In 2019, there was an estimated total of 197.22, 77.19 and
113.44 million cases of IHD, IS, and PAD, respectively.
Among them, 15.93%, 23.82%, and 13.65% of IHD, IS,
and PAD cases, respectively, occurred in individuals aged
20–54 years. Regarding mortality rate, IHD accounted
for the highest number of ASCVD-related mortality with
9.14 million deaths in 2019, followed by IS with 3.29 million deaths and PAD with 74,062 deaths. Among these,
11.08% of IHD mortality, 3.10% of IS mortality, and 2.34%
of PAD mortality occurred in the 20–54 years age group.
Meanwhile, individuals aged 20–54 years accounted for
24.74% for IHD DALYs, 11.10% for IS DALYs, and 4.96%
for PAD DALYs. (Fig. 1A–C).

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The proportion of younger patients with ASCVD was
greater in regions with lower SDI values. In 2019, theprevalence of younger IHD, IS, and PAD in low SDI
regions reached 20.70%, 40.05%, and 19.31%, respectively.
The differences in mortality rates and DALYs acrossregions were also similar to the differences in prevalence(Fig. 1A–C).The incidence of early-onset ASCVD washigher in males than in females (Additional file 1: Figure
S1–S2).
Temporal trends in global ASCVD burden: 1990–2019
comparison between individuals aged 20–54 and > 55
years

It was estimated that the global prevalence rates of IHD,
IS, and PAD in the 20–54 years age group increased by
20.55% (from 694.74 to 837.49 per 100,000 population),
11.50% (from 439.48 to 490.03 per 100,000 population),and 7.38% (from 384.24 to 412.59 per 100,000 population) across 1990–2019, respectively. Meanwhile, theglobal prevalence rates of IHD, IS, and PAD in individuals
aged > 55 years decreased by 1.26%, 0.13%, and 17.26%,
respectively (Additional file 1:Table S2–S7, Fig. 1D–F).
The burden of adverse outcomes, including mortality rates and DALYs, varied among ASCVD subtypes.
The decline in adverse outcomes for IHD and IS was
more significant in individuals aged > 55 years than in theyounger group. For PAD, DALYs increased among those
aged 20–54 years but decreased among those aged > 55
years. (Additional file 1:Table S2–S7, Fig. 1D–F).
ASCVD burden for individuals aged 20–54 and > 55 years
across locations in 2019

In 2019, the relationship between age-specific rates ofprevalence, death, and DALYs of IHD and IS with SDI
followed an inverse U-shaped curve in both the 20–54
and > 55 years age groups. Higher prevalence rates wereobserved in countries with a high-middle SDI, whereas
higher mortality/DALY rates were observed in countries with a low-middle SDI. Additionally, the age-specific rates of death and DALYs of PAD in the > 55 years
age group were positively correlated with SDI (P < 0.05),
which was not observed in the 20–54 years age group(Fig. 2, Additional file 1: Figure S3–S5).
At the regional level, similar distribution characteristics were observed in the ASCVD burden groups aged
20–55 and > 55 years. Eastern Europe had the highest
mortality rates and DALYs attributable to IHD, IS, and
PAD in 2019. Meanwhile, the highest prevalence of IHD
in younger patients was observed in North Africa andthe Middle East (Additional file 1: Table S2–S7). Tables
S8–S10 present the ASCVD burden in the 20–54 and > 55
age groups across countries and territories.

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Fig. 1 Global burden of ASCVD in the younger and the older. A Proportion of people aged 20–54 in total IHD burden. B Proportion of people aged
20–54 in total IS burden. C Proportion of people aged 20–54 in total PAD burden. D The rates of global IHD burden in people aged 20–54 and older
than 55 during 1990 and 2019. E The rates of global IS burden in people aged 20–54 and older than 55 during 1990 and 2019. F The rates of global
PAD burden in people aged 20–54 and older than 55 during 1990 and 2019.ASCVD: atherosclerotic cardiovascular disease; IHD: ischemic heartdisease; IS: ischemic stroke; PAD: peripheral artery disease; SDI: socio-demographic index; DALYs: disability-adjusted life years

Temporal trends in ASCVD burden across regions:
1990–2019 comparison between individuals aged 20–54
and > 55 years

The prevalence rate of IHD in individuals aged 20–54
increased across all five SDI categories from 1990 to
2019, with the highest EAPC observed in the middle SDI
regions (1.20 [95% confidence interval [CI]: 1.14–1.27]).
Conversely, during the same period, the increase of
IHD cases among older individuals in high- and highmiddle SDI regions was mitigated (EPAC < 0). Although
there was a significant decline in IHD mortality and
DALY rates among the 20–54 years age group in highSDI regions over the past 30 years, it was comparatively
smaller than that observed in the > 55 years age group(Additional file 1: Tables S2–S3, Fig. 2). The temporal
trends of IS burden across SDI regions mirrored those of
IHD (Additional file 1: Tables S3 and S6 and Fig. 2).
The prevalence rate (EAPC: -1.24 (95% CI: -1.39 to-1.10) and DALYs (EAPC: -0.15 (95% CI: -0.19 to -0.12))
of PAD in the > 55 years age group in high SDI regions
decreased over the past 30 years, whereas the burden of
PAD in the 20–54 years age group increased in almost all
sub-SDI regions, especially in the middle and low-middle

SDI regions (EAPC for PAD prevalence in middle SDI
regions: 1.57 [95% CI: 1.48–1.67]; EAPC for PAD mortality in low-middle SDI regions: 2.12 [95% CI: 2.00–2.25];
EAPC for PAD DALYs in low-middle SDI regions: 1.76
[95% CI: 1.64–1.88]) (Additional file 1: Table S2 and S5and Fig. 2).
East Asia exhibited the most rapid increase in IHD
prevalence burden during 1990–2019 both in the 20–54
and > 55 years age groups. Among the 20–54 years age
group, high-income North America demonstrated
the fastest increase in IS prevalence rate (EAPC: 1.52
[95% CI: 1.19–1.86]), whereas East Asia had the fastest increase among the > 55 years age group (EAPC:
1.40 [95% CI: 1.32–1.47]). Southeast Asia had the fastest
increase in mortality and DALY rates for IHD among the
20–54 years age group, with East Asia having the fastest increase in among the > 55 years age group. Both the
20–54 and the > 55 years age group in Southeast Asia had
the fastest increase in adverse outcomes for PAD (Tables
S4 and S7 and Fig. 3). The temporal trends of ASCVD
burden in both age groups according to country and territory are presented in Fig. 4 and Table S11–S12 and Figure S6–S7 in Additional file 1.

Li et al. BMC Medicine(2024) 22:303

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Fig. 2 The rate of ASCVDs burden by SDI during 1990–2019. A The rate of IHD burden in people aged 20–54 during 1990–2019. B The rate of IHD
burden in people older than 55 during 1990–2019. C The rate of IS burden in people aged 20–54 during 1990–2019. D The rate of IS burdenin people older than 55 during 1990–2019. E The rate of PAD burden in people aged 20–54 during 1990–2019. F The rate of PAD burden in people
older than 55 during 1990–2019. SDI: socio-demographic index; IHD: ischemic heart disease; IS: ischemic stroke; PAD: peripheral artery disease;
DALYs: disability-adjusted life years

ASCVD burden by sex and age

In 2019, global rates of prevalence, death, and DALYs
for ASCVD were higher in males than in females inboth the 20–54 and > 55 years age groups, except forthe prevalence rates of IS and PAD. The male-to-female
ratio of the ASCVD burden in the 20–54 years age
group globally and in most SDI regions was significantly
higher than that in the > 55 years age group. Notably,
the male-to-female ratio of ASCVD burden rates varied over time, with the sex gap in the 20–54 years age
group decreasing in high SDI regions and increasing inin low and low-middle SDI regions. Simultaneously, themale-to-female ratio of the ASCVD burden in the > 55
years age group remained stable in most regions (Fig. 4,
Additional file 1: Figure S8). Overall, the age-specificprevalence, mortality, and DALY rates for all three
types of ASCVDs increased with age, both globally andsub-SDI regionally (Additional file 1: Figures S9–S12).

Attributable risk factors for death and DALYs of ASCVDin individuals aged 20–54 and > 55 years

Metabolic and behavioral risk factors drove changes in
the overall ASCVD burden both in the 20–54 and > 55
years age groups during 1990–2019 (Additional file 1:
Figure S13–S16). Most risk factors exerted a greater
influence on the 20–54 years group than on the > 55
years age group, except for secondhand smoking, fasting plasma glucose level, high systolic blood pressure,
low physical activity, and lead exposure. In addition, thecontribution of risk factors varied between sexes in the
20–54 and > 55 years age groups. For instance, the contribution of high body-mass index was higher in females
than in males, whereas the contribution of hypertension
was higher in males. Males were also more likely to beaffected by smoking, whereas females were more likely tobe affected by exposure to secondhand smoking. (Fig. 5,
Additional file 1: Figure S17–S21).

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Fig. 3 The change of IHD burden by countries and territories during 1990–2019. A The change of IHD prevalence cases in people aged 20–54
by countries and territories in 2019. B The change of IHD prevalence cases in people older than 55 by countries and territories in 2019. C The
change of IHD death cases in people aged 20–54 by countries and territories in 2019. D The change of IHD death cases in people older than 55
by countries and territories in 2019. E The change of IHD DALYs cases in people aged 20–54 by countries and territories in 2019. F The change
of IHD DALYs cases in people older than 55 by countries and territories in 2019. IHD: Ischemic heart disease. DALYs: disability-adjusted life years

Regarding the burden of IHD and IS, mortality and
DALY rates attributed to almost all risk factors in
the > 55 years age group decreased significantly, with
their annual change rates surpassing those observed in
the 22–54 years age group. However, ambient particulate matter pollution, high body-mass index, and highfasting plasma glucose-induced IHD and IS burdens in
the 20–54 years age group have increased over the past
30 years. In particular, high fasting plasma glucoseand high systolic blood pressure-induced PAD burden
increased in the 20–54 years age group, whereas lead
exposure-induced PAD burden increased in the > 55
years age group (Additional file 1: Figures S22–S27).

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Fig. 4 The man to women ratio of the rate of global ASCVDs burden during 1990–2019. A The man to women ratio of the rate of global IHD
prevalence during 1990–2019. B The man to women ratio of the rate of global IHD death during 1990–2019. C The man to women ratio of the rateof global IHD DALYs during 1990–2019. D The man to women ratio of the rate of global IS prevalence during 1990–2019. E The man to women ratioof the rate of global IS death during 1990–2019. F The man to women ratio of the rate of IS DALYs during 1990–2019. G The man to women ratioof the rate of PAD prevalence during 1990–2019. H The man to women ratio of the rate of PAD death during 1990–2019. I The man to women ratioof the rate of PAD DALYs during 1990–2019. ASCVD: atherosclerotic cardiovascular disease; IHD: ischemic heart disease; IS: ischemic stroke; PAD:
peripheral artery disease; SDI: socio-demographic index; DALYs: disability-adjusted life years

Comparison of disease burden among extremelypremature (age < 40 years), premature (age < 55 years
in males; age < 65 years in females), and non‑premature
ASCVD (age ≥ 55 years in males; age ≥ 65 years in females)

The burden of premature ASCVD (age < 55 years inmales; age < 65 years in females) and non-premature
ASCVD (age ≥ 55 years in males; age ≥ 65 years infemales) were attributed to IHD, IS, and PAD. However, the burden of extremely premature ASCVD(age < 40 years) was only attributed to IHD and IS. By
2019, premature IHD comprised 16.80% of all IHD
prevalence cases in males, with extremely prematurecases accounting for 2.72%. Meanwhile, premature andextremely premature IS represented 28.30% and 12.49%
of total IS prevalence cases in males, respectively. Additionally, premature PAD accounted for 14.43% of the

PAD prevalence in males. The proportions of premature and extremely premature ASCVD have decreased
over the past 30 years (Figure S28). The proportion ofpremature ASCVD prevalence in females (IHD: 34.05%;
IS: 45.31%; PAD: 33.86%) was higher than that in males(IHD: 16.08%; IS: 28.03%; PAD: 14.43%) (Additional
file 1: Figure S28). Furthermore, the burden of premature and extremely premature ASCVD increased as the
SDI decreased (Additional file 1: Figure S29–S31).
Different ASCVD subtypes exhibited varying trends
in disease burden. In terms of IHD, non-prematurecases saw a decline from 1990 to 2019 globally (female
EAPC: -0.1 [95% CI: -0.12 to -0.09]; male EAPC:-0.13 [95% CI: -0.18 to -0.09]), whereas prematureand extremely premature IHD cases increased, with

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Fig. 5 PAF of risk factor for IHD death for different gender. A PAF of risk factor for IHD death for both genders. B PAF for risk factor of IHD death
for women. C PAF of risk factor for IHD death for male. PAF: population attribution fractions

Li et al. BMC Medicine(2024) 22:303

premature IHD showing a steeper rise in both sexes.
Over the past three decades, the prevalence of IS has
increased across all groups, except for non-premature
IS in females (EAPC: -0.08 [95% CI: -0.15 to -0.02]).
Particularly, the global prevalence of premature IS has
increased faster than extremely premature IS acrossboth sexes. In contrast to the decline in non-premature PAD (female EAPC: -0.71 [95% CI: -0.78 to -0.64];
male EAPC: -0.55 [95% CI: -0.59 to -0.5]), the global
prevalence of premature PAD increased. Regarding theburden of mortality and DALY rates, there was a significant decrease in non-premature and extremely premature ASCVD among females, whereas the burden ofpremature ASCVD remained unchanged or increased
over the past 30 years. Meanwhile, the risk of premature ASCVD mortality and DALYs in males continued
to increase (EAPC > 0), contrasting with the non-premature populations (Additional file 1: Table S13–S26,
Additional file 1: Figure S32–33).
Different SDI regions demonstrated different trends in
ASCVD burden. Although the prevalence of non-premature ASCVD in high SDI areas decreased, the prevalenceof non-premature ASCVD in low-middle and middle SDI
areas continued to increase for both sexes. Specifically,
the prevalence of premature and extremely premature
ASCVD increased in all SDI regions from 1990 to 2019,with the fastest-growing regions being the middle or lowmiddle SDI regions (Additional file 1: Tables S13–S26,
Figures S34–S36).

Discussion
Although the majority of the ASCVD burden occurs
in older individuals, the ASCVD burden in young individuals is becoming increasingly noteworthy owing tochanges in risk factors [21–24]. Recent findings indicate
a concerning trend of CVD events occurring at younger
ages [3, 25]. Approximately one-seventh of CVD eventsin females and a quarter of CVD events in males occur
before the age of 55 years [26]. To the best of our knowledge, this study is the first to evaluate the global prevalence of premature ASCVD. In the present study, we
found that, by 2019, 16.08%, 28.03%, and 14.43% of
IHD, IS, and PAD cases, respectively, occurred in males
aged < 55 years, whereas 34.05%, 45.31%, and 33.86%
of IHD, IS, and PAD cases, respectively, occurred infemales aged < 65 years. Additionally, regions with lower
SDI demonstrated a higher proportion of premature
ASCVD burden. Moving forward, prioritizing interventions for premature ASCVD in regions with lower SDI isimperative.
Over the past decade, public health strategies for
ASCVD have impacted the global ASCVD burden[12]. However, small-scale population studies suggest

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that trends in the burden of early-onset ASCVD and
ASCVD in older adults may differ [4, 6]. Previously,
data on disease burden mostly analyzed the burden ofa single specific age group, which may fail to provide
a clear indication of whether public health strategies
need to focus on specific groups of individuals [2, 3]. In
this study, we compared the ASCVD burden between
young and older individuals. We found that the mortality rates and DALYs of IHD and IS decreased inboth age groups, but the decrease was smaller in theyounger group. Notably, the prevalence of ASCVD in
older adults has decreased owing to the global focus
on chronic diseases. However, the number of young
patients with ASCVD has been increasing globally,
indicating an urgent need for measures to control the
spread of ASCVD in young adults.
An important feature of this study was the division of
the ASCVD burden into premature and non-prematuregroups according to clinical definitions. Previous studies have separately reported the CVD burden of young(age 15–39 years) and older (age > 70 years) groups [2, 3];
however, these findings may lack clinical relevance as the
population was not divided according to clinical definitions. Hence, in this study, we conducted a comparative
analysis of the burden of extremely premature, premature, and non-premature ASCVD in males and females
according to specific guidelines, providing new evidence
for clinical practice.
Interventions in risk factors might partially explain
the trend differences in ASCVD burden between young
and older individuals. Metabolic risk factors stand out aspivotal contributors to the global burden of IHD and IS.
Over the past decades, the global disease burden attributable to a high body-mass index has more than doubled[27], and the mortality and DALY rates due to high systolic blood pressure increased by 54.1% [28]. Simultaneously, the prevalence rate of metabolic factors in young
individuals has gradually been increasing [29]. Therefore,
the control and management of metabolic risk factors are
essential to reduce the ASCVD burden in young individuals. Our research suggests a deficiency in the past
control of risk factors among this demographic. While
the reduction in ASCVD burden caused by certain risk
factors is significantly lower in young individuals than inolder individuals, the burden of ASCVD caused by ambient particulate matter pollution, high body-mass index,
and high fasting plasma glucose is still increasing among
the young population. Drawing from the experiences of
preventing and controlling risk factors in older individuals, it is evident that a significant portion of the ASCVD
burden in young individuals can be prevented. Therefore,
implementing targeted prevention strategies for risk factors in young individuals deserves greater attention.

Li et al. BMC Medicine(2024) 22:303

The burden of ASCVD differs between young and older
individuals in terms of sex differences. Males generally
exhibit a higher rate of mortality and DALY burden of
IHD, IS, and PAD compared with females, regardless ofage, and this could be attributed to the cardioprotective
effects of estrogen [30]. However, the differences between
sexes in ASCVD are more pronounced among the young
demographic. Behavioral factors and the accessibilityof medical resources may contribute to these variations
across age groups. Notably, the disparity in smoking andalcohol consumption between sexes is more prominent
among young individuals [31, 32]. Additionally, young
males may exhibit poorer medical compliance to drug
therapy [33].
PAD exhibits distinct patterns in terms of burdenchanges compared with IHD and IS. The mortality
rate due to PAD has increased in both young and older
patients over the past 30 years. This contrasting trend
may be due to the lower awareness of PAD comparedwith IHD or IS. Only 25.8% of individuals are aware of
PAD, which is significantly lower than the awareness ofstroke and coronary artery disease [34]. Moreover, inadequate treatment for early PAD is another significant
factor contributing to the increasing trends in mortality
and DALY rates. In developed countries, approximately
one-third to half of PAD patients fail to receive long-term
statin and antiplatelet therapy [35]. Given these circumstances, there is an urgent need to increase attention to
PAD and implement standardized diagnosis and treatment protocols for both young and older individuals.
Limitations

To the best of our knowledge, this is the first study tocomprehensively assess the difference in ASCVD burden between young and older individuals. These findings
will be beneficial for public health policymakers. However, this study has some limitations. First, our attempt
to categorize ASCVD burden based on age cutoffs of 55
years for males and 65 years for females to delineate premature ASCVD and < 40 years for extremely premature
ASCVD may underestimate the burden of these conditions. The effects of premature and extremely premature
ASCVD can persist beyond these age thresholds, leading to potential underestimation of their burden while
possibly overestimating the burden of non-premature
ASCVD. Second, as the ASCVD data within the 2019
GBD study were based on secondary data from existing registers, bias and gaps could not be avoided in themodeling process related to ASCVD burden estimation.
Third, the accuracy of fatal and nonfatal ASCVD burdens depends on detection methods, screening quality,and data registry, which are influenced by socioeconomic

Page 10 of 12

factors. Consequently, the ASCVD burden in countries
with lower SDI may be underestimated.

Conclusions
Although the ASCVD burden on older individuals isdecreasing, it is increasing among young individuals,
particularly in areas with lower levels of socioeconomic
development. The increasing susceptibility of young
individuals to the impact of ambient particulate matter pollution, as well as their insufficient control of highbody-mass index and high fasting plasma glucose, may
contribute to the disparity in the temporal trends of the
ASCVD burden between young and older individuals.
This evidence forms the foundation for the developmentof targeted public health policies.
Abbreviations
ASCVDs	Atherosclerotic cardiovascular disease
IHD	Ischemic heart diseaseIS	Ischemic stroke
PAD	Peripheral artery disease
PAF	Population attribution fractions
SDI	Socio-demographic index
DALY	Disability-adjusted life years

Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12916-​024-​03527-4.
Additional file 1: Table S1 Definition of risk factors. Table S2 IHD burdenin people aged 20–54 across regions. Table S3 IS burden in people aged
20–54 across regions. Table S4 PAD burden in people aged 20–54 acrossregions. Table S5 IHD burden in people older than 55 + across regions.
Table S6 IS burden in people older than 55 + across regions. Table S7 PAD
burden in people older than 55 + across regions. Table S8 IHD burden in
204 countries and territories by 2019. Table S9 IS burden in 204 countries
and territories by 2019. Table S10 The PAD burden in 204 countries andterritories by 2019. Table S11 The temporal trends of ASCVDs burdenin people aged 20–54 in 204 countries and territories. Table S12 The
temporal trends of ASCVDs burden in people older than 55 in 204
countries and territories. Table S13 IHD burden in people under 40 across
SDI regions. Table S14 IS burden in people under 40 across SDI regions.
Table S15 IHD burden under 55 for male across SDI regions. Table S16
IS burden under 55 for male across SDI regions. Table S17 PAD burden
under 55 for male across SDI regions. Table S18 IHD burden under 65 forfemale across SDI regions. Table S19 IS burden under 65 for female across
SDI regions. Table S20 IHD burden older than 65 for female across SDI
regions. Table S21 IHD burden older than 65 for female across SDI regions.
Table S22 IS burden older than 65 for female across SDI regions. Table S23
PAD burden older than 65 for female across SDI regions. Table S24 IHD burden older than 55 for male across SDI regions. Table S25 IS burden older
than 55 for male across SDI regions. Table S26 PAD burden older than 55
for male across SDI regions. Figure S1 Proportion of people aged 20–54 intotal men ASCVDs burden during 1990–2019. Figure S2 Proportion of people aged 20–54 in total women ASCVDs burden during 1990–2019. Figure
S3 Association between SDI and age-specific prevalence, death and DALYs
rates of IHD in 2019. Figure S4 Association between SDI and age-specificprevalence, death and DALYs rates of IS in 2019. Figure S5 Association
between SDI and age-specific prevalence, death and DALYs rates of PAD
in 2019. Figure S6 The change of IS burden by countries and territories
during 1990–2019. Figure S7 The change of PAD burden by countries andterritories during 1990–2019. Figure S8 The men to women ratio of therate of ASCVDs burden by SDI region. Figure S9 The rates of global ASCVDs

Li et al. BMC Medicine(2024) 22:303

burden in different age group during 1990–2019. Figure S10 The ratesof IHD burden by age group in different SDI region. Figure S11 The ratesof IS burden by age group in different SDI region. Figure S12 The rates of
PAD burden by age group in different SDI region. Figure S13 The rate of
ASCVDs death in people aged 20–54. Figure S14 The rate of ASCVDs DALYs
in people aged 20–54. Figure S15 The rate of ASCVDs death in people
older than 55. Figure S16 The rate of ASCVDs DALYs in people older than
55. Figure S17 PAF of risk factor for IHD DALYs for different sex. Figure S18
PAF of risk factor for IS deaths for different sex. Figure S19 PAF of risk factor
for IS DALYs. Figure S20 PAF of risk factor for PAD deaths. Figure S21 PAF ofrisk factor for PAD DALYs. Figure S22 Annual change of risk factor induced
IHD death rate. Figure S23 Annual change of risk factor induced IHD DALYs
rate. Figure S24 Annual change of risk factor induced IS death rate. Figure
S25 Annual change of risk factor induced IS DALYs rate. Figure S26 Annualchange of risk factor induced PAD death rate. Figure S27 Annual changeof risk factor induced PAD DALYs rate. Figure S28 The proportion of global
extremely premature, premature and non-premature ASCVD burden bygender. Figure S29 The proportion of extremely premature, prematureand non-premature IHD burden. Figure S30 The proportion of extremelypremature, premature and non-premature IS burden. Figure S31 The
proportion of extremely premature, premature and non-premature PAD
burden. Figure S32 The rates of global extremely premature, prematureand non-premature ASCVD burden for male. Figure S33 The rates of global
extremely premature, premature and non-premature ASCVD burden
for female. Figure S34 The rates of extremely premature IHD, premature
IHD and non-premature IHD burden. Figure S35 The rates of extremelypremature IS, premature IS and non-premature IS burden. Figure S36 The
rates of extremely premature PAD, premature PAD and non-premature
PAD burden.
Acknowledgements
We are grateful to the Institute of Health Metrology and Evaluation for sharing
valuable GBD data.
Authors’ contributions
HB Z, W L and YX L had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. HB Z,
ZY L, W L and YX L planned the concept of this study. HB Z, ZY L, YCH Y, XCH, N
Y, LL X and YX L conducted data extraction and analysis. ZY L, LY H, JL W, F P, LL
X and W L carried out data cleaning and material support. All authors criticallyreviewed, revised, and contributed to the final manuscript. The corresponding
author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding
This work was supported by grants from CAMS Innovation Fund for Medical
Sciences (CIFMS, 2023-I2M-C&T-B-043), the National High level Hospital Clinical Research Funding (2022-PUMCH-B-015), the CAMS Innovation Fund for
Medical Sciences (CIFMS, 2021-I2M-1-002), and the National Natural Science
Foundation of China (No. 82200992).
Availability of data and materials
Relevant data can be retrieved through the available website (https://​vizhub.​healt​hdata.​org/​gbd-​resul​ts/).

Declarations
Ethics approval and ethics approval and consent to participate
For the GBD is publicly available and no identifable information was includedin the analyses, the ‘Ethical approval and Ethics Approval and Consent toParticipate’ was not applicable.
Consent for Publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.

Page 11 of 12

Author details
1
Department of Endocrinology, Key Laboratory of Endocrinology of National
Health Commission, Translation Medicine Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical
College, No.1 Shuaifuyuan, Beijing, Wangfujing, Dongcheng District, China.
2
Diabetes Research Center of Chinese Academy of Medical Sciences, Beijing,
China.
Received: 3 February 2024 Accepted: 10 July 2024

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