Low- and lower-middle-SDI countries face a rapidly growing burden of hypertensive heart disease, with deaths increasing approximately 192% from 1990 to 2023, cold temperature representing an important environmental contributor, and projections indicating further marked increases by 2050 driven mainly by population ageing among women.
Deaths from hypertensive heart disease in low- and lower-middle-SDI countries combined increased by approximately 192% from 1990 to 2023.
Age-standardised mortality rates increased significantly in low-SDI countries but not significantly in lower-middle-SDI countries.
Cold temperature consistently contributed a greater temperature-attributable HHD burden than high temperature throughout the entire study period from 1990 to 2023.
Cross-country absolute socioeconomic inequality in HHD burden widened substantially over the study period.
Bayesian age-period-cohort model projections indicate that HHD deaths and DALYs will increase markedly by 2050, driven mainly by population ageing among women.
This research suggests that hypertensive heart disease — a condition where high blood pressure damages and weakens the heart — has become dramatically more deadly in the world's poorest countries over the past three decades. Using data from the Global Burden of Disease Study 2023, researchers found that deaths from this condition nearly tripled (increased by about 192%) between 1990 and 2023 in low- and lower-middle-income countries, with total deaths rising from roughly 158,000 to 461,000 per year. Central Sub-Saharan Africa was identified as the hardest-hit region, with the highest death rates globally. The gap in disease burden between richer and poorer countries also grew wider over this period, meaning the inequality problem is getting worse, not better. One notable finding is that cold weather exposure was a more important environmental driver of hypertensive heart disease deaths than hot weather exposure throughout the entire study period. This may seem counterintuitive given that many of these countries are in tropical or warm regions, but cold spells — even in warmer climates — can raise blood pressure and stress the cardiovascular system. While the overall number of cold-weather-related deaths grew, rates of cold-attributable disease remained relatively stable, suggesting cold exposure is a persistent but not rapidly worsening contributor compared to other factors driving the overall rise in burden. Looking ahead to 2050, the models project that hypertensive heart disease deaths and disability will continue to rise sharply in these countries, with older women being the group most affected by this projected increase. This research suggests that addressing this crisis will require a combination of approaches: better access to blood pressure treatment, as well as low-cost, practical strategies to protect people from cardiovascular harm during cold periods. The findings highlight that environmental factors like cold temperature should be considered alongside healthcare access and population ageing when designing public health responses to heart disease in the world's most vulnerable countries.
Ruan M, Zhang R, Wei J, Niu T, Wang S, Shi W, et al.. (2026). Accelerating Burden of Hypertensive Heart Disease in Low- and Lower-Middle-SDI Countries, 1990-2023: The Contribution of Cold Temperature Exposure.. Annals of global health. https://doi.org/10.5334/aogh.5329