Global burden of rheumatic heart disease: trends from 1990 to 2019

Trends in incidence of RHD

Globally, the incident number of RHD was about 2.79 million in 2019, with an increase of 49.70% since 1990. The overall age-standardized incidence rate (ASIR) was 37.40/100,000 in 2019, and increased with an annual average 0.58% from 1990 to 2019 (EAPC = 0.58, 95%CI 0.52 to 0.63) (Table 1; Fig. 1). Compared to males, females had higher incident numbers, while showing a lower increasing trend of ASIR (Table 1). The highest incident number of RHD was observed in the age group of 10-14 years in 2019, and decreasing percent changes in number only occurred in those aged 50-54 years from 1990 to 2019 (Additional file 1: Table S1; Fig. 2A). Among the SDI areas, a pronounced increasing trend of ASIR was seen in the low SDI area (EAPC = 0.30, 95%CI 0.24 to 0.36). In contrast, decreasing trends occurred in high-middle and high SDI areas, particularly the latter (EAPC = − 0.58, 95%CI − 0.74 to − 0.41). In terms of regions, the largest percent increase in incident number was found in western Sub-Saharan Africa (156.05%), while the largest decrease was in Central Europe (− 39.78%). The increasing trends of ASIRs appeared in nine regions, particularly Oceania (EAPC = 0.34, 95%CI 0.27 to 0.40). Conversely, the decreasing trends occurred in seven regions, and the largest one was in Eastern Europe (EAPC = − 2.15, 95%CI − 2.26 to − 2.04), followed by Central Europe and High-income Asia Pacific (Table 1; Figs. 1 and 2B, C). In 2019, the ASIRs were heterogeneous between countries from 1.48/100,000 in Finland to 93.95/100,000 in Uganda. The highest increasing percentages of the incident number were seen in Qatar (376.94%) and United Arab Emirates (278.52%), while the largest decrease was in Latvia (− 57.87%). The increasing trends of ASIR were observed in sixty-five countries/territories, particularly Fiji and Belgium, in which the respective EAPCs were 2.17 (95%CI 1.48 to 2.86) and 1.08 (95%CI 0.76 to 1.39). Conversely, the ASIRs showed decreasing trends in 119 countries/territories, particularly Finland (EAPC = − 3.87, 95%CI − 4.18 to − 3.56), followed by Norway and Singapore (Additional file 1: Table S2; Fig. 3A-C). EAPCs had a positive relationship with the ASRs in 1990 (ρ = 0.61, p < 0.001; Fig. 4A), and had a negative relationship with HDI (ρ = − 0.58, p < 0.001; Fig. 5A).

Trends in prevalence of RHD

During 1990-2019, the global RHD prevalence increased by 70.49% and reached 40.50 million in 2019. The total ASR of prevalence was 513.68/100,000 in 2019, and the overall ASR had an increasing trend (EAPC = 0.57, 95%CI 0.50 to 0.63) (Table 1; Fig. 1). Compared with males, females had a higher prevalence number, while showing a lower increasing trend of ASRs (Table 1). The highest RHD prevalence was observed in the age group of 25-29 years in 2019, and the increasing percentage occurred in all age groups, particularly those aged above 80 years (140.36%) (Additional file 1: Table S1, Fig. S1A). The ASRs of prevalence had increasing trends in low, low-middle, and middle SDI areas, while decreasing in high SDI areas (EAPC = − 0.27, 95%CI − 0.41 to − 0.13). In 21 geographic regions, the highest RHD prevalent number was found in South Asia (12.17 million), and the largest increasing percent occurred in Western Sub-Saharan Africa (162.05%). The increasing trends of ASRs were observed in twelve regions, particularly Oceania (EAPC = 0.34, 95%CI 0.27 to 0.41). However, decreasing trends were found in ten geographic regions, especially in Eastern Europe (EAPC = − 1.62, 95%CI − 1.82 to − 1.42), followed by High-income Asia Pacific and Central Europe (Table 1; Fig. 1, and Additional file 1: Fig. S1B-C). At the national level, the largest increasing prevalence number was observed in the United Arab Emirates (494.57%), whereas the largest decreasing one was in Moldova (− 43.34%). The trends of prevalent ASRs increased in ninety-seven countries/territories, and the most pronounced ones occurred in Fiji (EAPC = 2.22, 95%CI 1.53 to 2.91). However, the trends declined in ninety-one countries/territories, particularly Finland (EAPC = − 3.41, 95%CI − 3.86 to − 2.96), followed by Austria and Singapore (Additional file 1: Table S2, Fig. S2A-C). EAPCs had a positive relationship with the ASRs in 1990 (ρ = 0.59, p < 0.001; Fig. 4B), and had a negative relationship with HDI (ρ = − 0.58, p < 0.001; Fig. 5B).

Trends in death due to RHD

The death number of RHD was about 0.31 million worldwide in 2019, with a decrease of 15.60% since 1990. The overall age-standardized death rate (ASDR) of RHD was 3.85/100,000 in 2019, and presented a decreasing trend during 1990-2019 (EAPC = − 2.98, 95%CI − 3.03 to − 2.94) (Table 2; Fig. 1). Female patients had a higher death number, while showing a larger decreasing trend of ASDR (EAPC = − 3.10, 95%CI − 3.17 to − 3.03) (Table 2). The highest number of RHD prevalence was observed in the age group above 80 years, and the largest decreasing changes in number occurred in those aged under 5 years (− 75.35%) (Additional file 1: Table S1, Fig. S3A). Trends in ASDR of RHD decreased in sexes, SDI areas, and geographic regions from 1990 to 2019, particularly the high-middle SDI areas (EAPC = − 4.53, 95%CI − 4.67 to − 4.39). At the regional level, Central Europe and Eastern Europe had the most pronounced decreasing trends, with the respective EAPCs being − 5.72 (95%CI − 6.14 to − 5.29) and − 5.58 (95%CI − 6.07 to − 5.09) (Table 2; Fig. 1, and Additional file 1: Fig. S3B-C). At the national level, the largest increasing change in the number of RHD was seen in United Arab Emirates (219.33%), whereas the largest decreasing one was in Latvia (− 83.32%). Decreasing trends in ASDR of RHD were observed in 200 countries/territories, particularly Thailand and the Syrian Arab Republic, in which the respective EAPCs were − 9.55 (95%CI − 10.48 to − 8.61) and − 8.28 (95%CI − 9.33 to − 7.22). However, increasing trends were found in only four countries, particularly Georgia and Belgium, with the respective EAPCs being 2.64 (95%CI 2.12 to 3.16) and 2.24 (95%CI 1.70 to 2.77) (Additional file 1: Table S3, Fig. S4A-C). EAPCs had a positive relationship with the ASRs in 1990 (ρ = 0.16, p = 0.025; Fig. 4C), and had a negative relationship with HDI (ρ = − 0.25, p < 0.001; Fig. 5C).

Trends in DALYs due to RHD

Globally, the number of DALYs due to RHD was 10.67 million in 2019, with a decrease of 18.94% since 1990. The total ASR of DALYs was 132.88/100,000 in 2019, and decreasing trend of ASR was observed worldwide from 1990 to 2019 (EAPC = − 2.70, 95%CI − 2.75 to − 2.65) (Table 2; Fig. 1). During 1990-2019, the percentage of DALYs number declined in all age groups under 80 years, particularly those under 5 years (− 73.74%) (Additional file 1: Table S1, Fig. S5A). Decreasing trends in ASRs of DALYs were seen in sexes, SDI areas, and geographic regions, particularly in the high-middle SDI area and Central Europe, in which the respective EAPCs were − 4.54 (95%CI − 4.67 to − 4.41) and − 6.23 (95%CI − 6.71 to − 5.76) (Table 2; Fig. 1, and Additional file 1: Fig. S5B-C). Among 204 countries/territories, the largest increasing percentage of DALY number was seen in United Arab Emirates (254.82%), whereas the most pronounced decreasing one was in Latvia (− 84.03%). Decreasing trends in ASRs of DALYs were seen in 200 countries/territories, particularly the Syrian Arab Republic (EAPC = − 7.36, 95%CI − 8.32 to − 6.38), followed by Poland and Latvia. However, increasing trends occurred in four countries, particularly the Philippines and Belgium, in which the respective EAPCs were 2.42 (95%CI 1.70 to 3.14) and 1.14 (95%CI 0.75 to 1.54) (Additional file 1: Table S3, Fig. S6A-C). EAPCs had a positive relationship with ASRs in 1990 at the national level (ρ = 0.19, p = 0.001; Fig. 4D), and had a negative relationship with HDI (ρ = − 0.40, p < 0.001; Fig. 5D).

Trends in attributable risk-related death and DALYs due to RHD

All the three attributable risk-related death caused by RHD showed decreasing trends worldwide from 1990 to 2019. Behavioral risk-related death due to RHD had the most significant decrease in number (− 37.73%) and the ASDR (EAPC = − 3.99, 95%CI − 4.06 to − 3.92) (Additional file 1: Table S4, Fig. S7A-B). Similar decreasing trends were observed in both sexes, particularly behavioral risk-related death in females (EAPC = − 4.50, 95%CI − 4.59 to − 4.41) (Additional file 1: Table S5, Fig. S8A-D). In SDI areas, the risk-related death due to RHD showed sharp decreasing trends in middle and high-middle SDI areas, particularly behavioral risk-related death in the high-middle SDI area, with the EAPC being − 5.28 (95%CI − 5.40 to − 5.16) (Additional file 1: Table S6).

The three attributable risk-related DALYs due to RHD showed pronounced decreasing trends globally from 1990 to 2019, particularly behavioral risk-related DALYs (EAPC = − 3.83, 95%CI − 3.91 to − 3.76) (Additional file 1: Table S4; Fig. S7C-D). Compared with males, more pronounced decreasing trends of risk-related DALYs due to RHD were observed in females, particularly the behavioral risk-related one (EAPC = − 4.39, 95%CI − 4.50 to − 4.28) (Additional file 1: Table S5, Fig. S9A-D). Meanwhile, the strong decreasing trends were also seen in all SDI areas, particularly environmental/occupational risk- and behavioral risk-related DALYs in the high-middle SDI areas, with the respective EAPCs being − 5.35 (95%CI − 5.56 to − 5.15) and − 5.09 (95%CI − 5.21 to − 4.97) (Additional file 1: Table S6).