The burden of non-rheumatic valve disease among China, the United States, India, and Central Africa from 1990 to 2021 and projections to 2040

Introduction

Valvular heart disease (VHD) refers to structural or functional abnormalities of the heart valves that prevent them from functioning properly, thereby affecting blood flow through the heart (1). Although rheumatic heart disease (RHD) was previously the predominant global cause of VHD, its incidence has substantially declined over the past four decades due to economic advancement and medical progress (2). Conversely, driven by population growth and aging, non-rheumatic valvular heart disease (NRVD) is becoming increasingly prevalent worldwide, with its incidence steadily rising (3). Global Burden of Disease (GBD) data indicate a 45.1% increase in NRVD incidence between 1990–2017 (4), contrasting with an 8.7% decline in RHD incidence. Given these divergent trends and substantial public health implications, a comprehensive assessment of NRVD’s global epidemiological burden is warranted.

The Central African Republic (CAR), India, China, and the United States (US) represent countries at varying levels of economic development as classified by the World Bank, with substantial differences in healthcare resource allocation and capacity for disease control. The CAR has long faced a high burden of VHD, primarily driven by RHD (5); however, epidemiological research on non-rheumatic valvular disease (NRVD) remains limited. The United States, as a representative high-income country, sees degenerative valvular disease as the primary cause of non-RHD (6). Benefiting from advanced medical technology, a comprehensive healthcare system, and abundant medical resources, the United States holds distinct advantages in NRVD screening, diagnosis, treatment, and rehabilitation. As the world’s most populous country, China possesses a large population of valvular disease patients, which lends broad representativeness and practical significance to NRVD analyses based on Chinese data (7). India, with a similarly large and growing population base, differs considerably from both China and the United States in terms of public health conditions, healthcare accessibility, and lifestyle patterns. As a result, its NRVD data carry unique value (8,9).

While existing GBD studies on NRVD have provided valuable insights into global and regional disease burdens, they often lack granular, country-specific epidemiological assessments. Given that healthcare policy and disease management are primarily implemented at the national level, with substantial variations in healthcare infrastructure, risk factor prevalence, and socioeconomic determinants across countries, a more detailed country-level analysis is warranted. Moreover, despite shared challenges in NRVD prevention and control, cross-country comparisons may reveal transferable best practices. To address these gaps, this study performs a comprehensive comparative analysis of NRVD burden-including incidence, mortality, and disability-adjusted life years (DALYs)—across four representative nations: the CAR (low-income), India and China (middle-income), and the US (high-income). By quantifying current trends and projecting future trajectories, this approach not only elucidates key epidemiological disparities and disease subtype distributions across income strata but also informs the development of tailored, evidence-based prevention strategies for diverse healthcare systems. We present this article in accordance with the STROBE reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2025-1-53/rc).

Methods

Data sources

The GBD 2021 database provides a comprehensive assessment of health loss due to 369 diseases, injuries, and impairments, and 88 risk factors across 204 countries and territories. Drawing on the most recent epidemiological data and a suite of standardized methods, it spans from January 1, 1990, to December 31, 2021 (10). Advanced statistical approaches—such as multiple imputation for missing data and adjustments for confounding—ensure that estimates are both robust and transparent, and full design and analytical protocols are documented in the published literature. Sample sizes vary by condition and location, reflecting the diversity of underlying data sources; burden estimates for NRVD were obtained directly from the Global Health Data Exchange (http://ghdx.healthdata.org/gbd-results-tool).

According to the above specifications, we extracted crude incidence, crude mortality, and DALYs rates for NRVD in China, the United States, India, and the Central African Republic from 1990 to 2021. All rates were age-standardized using the GBD 2021 global reference population. Temporal trends were analyzed by sex and age group. Corresponding population data required for projection calculations were also retrieved from the same platform. As the GBD data are publicly accessible, this study did not require ethical approval, and no personal information was collected, ensuring full compliance with privacy regulations. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Definitions

NRVD

NRVD is defined as structural or functional abnormalities of the cardiac valves caused by degenerative, congenital, or non-rheumatic inflammatory etiologies (11). According to the GBD 2021 classification, NRVD includes non-rheumatic calcific aortic valve disease (CAVD), non-rheumatic degenerative mitral valve disease (DMVD), and other specified non-rheumatic valvular lesions. Case identification is based on relevant ICD-9 and ICD-10 codes (12). For cases with ambiguous coding, diagnostic accuracy is further refined through the GBD garbage-code redistribution algorithm and Bayesian modeling.

CAVD, characterized by calcium deposition in aortic valve leaflets, is associated with aging, oxidative stress, and lipid metabolism dysfunction and includes aortic valve sclerosis and calcific aortic stenosis (AS) based on severity.

DMVD comprises mitral valve prolapse subtypes such as Barlow’s disease (myxomatous degeneration) and fibroelastic deficiency (11,13).

The remaining category serves as a supplementary classification to ensure comprehensiveness of the disease spectrum. It covers valve damage from non-rheumatic causes not captured above—primarily affecting the pulmonary and tricuspid valves, as well as selected aortic or mitral valve pathologies due to clearly non-rheumatic factors (e.g., infective endocarditis, ischemic heart disease, connective tissue disorders, or congenital anomalies) that do not meet the specific definitions for CAVD or DMVD.

In this study, analysis focuses primarily on the CAVD and DMVD subtypes.

DALYs

DALYs are a key health metric endorsed by the World Health Organization (WHO) to quantify the total population health burden of a disease or health condition. Developed by the WHO, DALYs integrate two components: years of life lost due to premature mortality (YLL) and years lived with disability (YLD), providing a unified framework for comparing disease impacts.

DALYs=YLLs+YLDs[1]

Statistical analysis

We conducted statistical analyses using R software (v4.4.1). Data on the incidence, prevalence, mortality, and DALYs of NRVD from 1990 to 2021 were extracted from the GBD 2021 database. For each metric, we calculated absolute counts, age-standardized rates (per 100,000 population), and percentage change intervals. All rates were age-standardized using the GBD 2021 standard population and are presented with 95% uncertainty interval (UI) derived from 1,000 posterior draws. Analyses were stratified by 23 age groups, sex, calendar year, and geographic region to assess the spatiotemporal patterns of disease burden. All data processing and visualization code is publicly available (https://ghdx.healthdata.org/gbd-2021/code).

To analyze temporal trends, we applied the Joinpoint regression model. This segmented regression technique identifies significant inflection points (joinpoints) in trends over time (14). The optimal number of joinpoints (0 to 5) was determined using a permutation test, guided by the Bayesian Information Criterion. Within each segment, a log-linear model was fitted to calculate the annual percent change (APC). The overall trend for 1990–2021 was summarized by the average annual percentage change (AAPC), a geometrically weighted average of the segment-specific APCs. An AAPC > 0 indicates an increasing trend, <0 a decreasing trend, and stability if its 95% confidence interval includes 0. Finally, we used Bayesian age-period-cohort modeling to project the burden of non-rheumatic valvular disease from 2022 to 2040 for global, regional, and four national contexts (China, Central African Republic, India, and the United States). This approach robustly accounts for data uncertainty and leverages out-of-sample information to generate reliable forecasts (15).

Results

Characterization of the burden of disease for NRVD globally and among representative countries

The global burden of NRVD exhibits marked socioeconomic gradients, with distinct variations in its epidemiological profile and etiological composition across nations of differing economic development (Table 1).

Among the four countries compared, the US demonstrated the highest incidence, mortality, and DALYs rates for NRVD. In 2021, the US age-standardized incidence rate (ASIR) reached 82.6 per 100,000, substantially higher than the global average of 25.0 per 100,000. China demonstrated the most rapid increase in ASIR for NRVD among the countries analyzed, alongside the lowest mortality burden. In 2021, China’s ASIR (12.7 per 100,000) remained below the global average (25.0 per 100,000), yet increased by 24.1% between 1990 and 2021, exceeding global growth trends. Despite this rising incidence, China maintained a low burden in mortality and disability, with an age-standardized mortality rate (ASMR) of 0.14 per 100,000 and an age-standardized DALYs rate of 4.9 per 100,000. Consequently, China contributed only 1.36% (n=2,458) of global NRVD deaths (N=181,078) in 2021 (Table 2; Table S1). The incidence of NRVD in India is relatively low, but the mortality rate is on the rise. In 2021, India’s ASIR, ASMR, and age-standardized DALYs rate were 5.3, 1.3, and 26.4 per 100,000, all below the global average. However, between 1990 and 2021, India’s ASMR and age-standardized DALYs rate increased by 20.0% and 12.9%, respectively, contrary to the global trend of declining mortality rates. The CAR demonstrates an epidemiological profile marked by relatively low incidence yet disproportionately high mortality for NRVD. In 2021, CAR’s ASIR was 3.0 per 100,000—below both the global average and rates observed in comparator nations. Although the ASIR is low, the mortality and disability burdens are high, second only to the US, with ASMR and age-standardized DALYs rate of 2.3 and 49.0 per 100,000. Among the subtypes of NRVD, the newly diagnosed cases in the four countries analyzed were predominantly DMVD, while CAVD was the primary cause of death. In the US, CAVD accounted for only 45.4% of new cases but 86.1% of deaths. In contrast, in China, DMVD was the predominant subtype in new cases (81.3%), while CAVD remained the primary cause of death (54.3%; Figure 1).

Figure 1 The age-standard incidence (A: 1990; B: 2021), mortality (C: 1990; D: 2021), and DALYs (E: 1990; F: 2021) rates of NRVD in the US, India, China, CAR, and global. ASDR, age-standardized disability-adjusted life years rate; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; CAR, Central African Republic; DALYs, disability-adjusted life years; NRVD, non-rheumatic valvular disease; US, United States.

Changes in the disease burden of NRVD from 1990 to 2021

Since 1990, the disease burden of NRVD has improved significantly worldwide. In 2021, most epidemiological indicators worldwide had declined significantly compared with 1990. However, trends varied across countries (Table 3). India, China, and the US generally exhibited an upward trend in incidence, while the CAR showed a downward trend (AAPC: −0.27%). CAR experienced a gradual increase in incidence from 1990 to the mid-1990s (AAPC: +0.40%), followed by a sustained decline. The incidence trend in India is roughly the opposite of that in the CAR. China maintained steady growth from 1990 to 2019, with the most significant acceleration occurring between 2006 and 2009 (APC: +3.76%)—during which the growth rate exceeded the global average (+1.28%) and that of the US (+1.25%). The US experienced significant growth from 1995 to 2000 (APC: +2.82%), followed by a period of fluctuation. Both China and the US saw a decline in incidence trends from 2019 to 2021. Trends in mortality rates and DALYs are generally consistent across countries. The disease burden in India is on the rise, with the most significant increase occurring between 2011 and 2014. In contrast, the US, the CAR, and China show an overall downward trend. The trends in ASMR and age-standardized DALYs rate in China and the US are similar to the global trends, with the most significant decline in China occurring between 2004 and 2009, and the fastest decline in the US occurring between 1997 and 2000. In contrast, the decline in the CAR has been relatively slow.

The change burdens also differed among disease subgroups. Globally, CAVD incidence rose (AAPC: +0.54%), while DMVD incidence declined (AAPC: −0.17%). The disease burden of CAVD increased in India (AAPC: +0.76%), whereas the burden of CAVD decreased in the US, China, and the CAR (Table S2; Figure 2).

Figure 2 Trends in incidence, mortality, and DALYs for NRVD in the CAR, China, Globally, India, and the US from 1990 to 2021. (A) Incidence trends. (B) Mortality trends. (C) Trends in DALYs. ASDR, age-standardized disability-adjusted life years rate; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; CAR, Central African Republic; DALYs, disability-adjusted life years; NRVD, non-rheumatic valvular disease; US, United States.

Age and gender distribution and trends in NRVD

Analyzing the burden of NRVD by age group and gender helps to gain a deeper understanding of the current epidemiological characteristics. As demonstrated in Figures 3,4 and Figure S1, the global NRVD burden exhibits significant sex disparities; males experience higher incidence and mortality rates, while females endure a greater burden measured by DALYs. The burden associated with NRVD exhibits a characteristic trend of increasing with age and then decreasing. Specifically, the incidence rate peaks in the 65−69 years age group; the peak in DALYs shows gender differences, with males peaking in the 80-84 age group and females peaking later, in the 85−89 years age group.

Figure 3 Age-specific counts of NRVD incidence globally and in selected countries from 1990 to 2021. Each panel shows: (A,B) Global; (C,D) the US; (E,F) the CAR; (G,H) China; (I,J) India. CAR, Central African Republic; NRVD, non-rheumatic valvular disease; US, United States.

Figure 4 Age-specific mortality counts for NRVD are presented for the global population and four selected countries from 1990 to 2021. Each panel shows: (A,B) Global; (C,D) the US; (E,F) the CAR; (G,H) China; (I,J) India. CAR, Central African Republic; NRVD, non-rheumatic valvular disease; US, United States.

According to data analysis from various countries, in China, the US, and the CAR, the incidence of NRVD and the burden of DALYs are higher in men than in women. However, as age increases, the burden of DALYs and mortality in women gradually exceeds that in men. Within the 75−79 years age group in the CAR and India, NRVD incidence rates are higher among females (Figures 5,6 and Figure S2). The trends in disease burden in China, the US, India, and the CAR are similar, characterized by an initial increase followed by a decline with age. However, the burden level in the US is significantly higher than in the other three countries. Regarding the peak age for NRVD mortality burden, the peak ages for men and women in the US are 85−89 and 90−94 years, respectively. In China, the peak ages are 75−79 years for men and 80−84 years for women. In the CAR, the peak ages are 60−64 years for men and 70−74 years for women. In India, the peak ages are 70−74 years for men and 75−79 years for women. Notably, the peak age of NRVD mortality in China and the US has generally been delayed by five years compared to 1990, and the peak age of mortality for women in most countries is generally later than that for men. No significant gender differences were observed in the age-specific peak burden of NRVD incidence, which was primarily concentrated among individuals aged 65−69 years. The DALYs burden also exhibits distinct age distribution characteristics: in the US, the peak for men is at 90−94 years, and for women at 85−89 years; in the CAR, the peaks for men and women are at 55−59 and 65−69 years, respectively; while in China and India, the peaks for both men and women occur in the 70−74 years age group (Figures 3,4 and Figure S1).

Figure 5 ASIR and number of incident cases for NRVD globally and in selected countries, stratified by sex and age group, 1990 (left panels) versus 2021 (right panels). Each pair of panels corresponds to: (A,B) Global estimates; (C,D) the US; (E,F) the CAR; (G,H) China; (I,J) India. ASIR, age-standardized incidence rate; CAR, Central African Republic; NRVD, non-rheumatic valvular disease; US, United States.

Figure 6 ASMR and number of deaths for NRVD globally and in selected countries, stratified by sex and age group, 1990 (left panels) versus 2021 (right panels). Each pair of panels corresponds to: (A,B) Global estimates; (C,D) the US; (E,F) the CAR; (G,H) China; (I,J) India. ASMR, age-standardized mortality rate; CAR, Central African Republic; NRVD, non-rheumatic valvular disease; US, United States.

Future projections of the burden of non-rheumatic valvular disease

Based on global disease burden data for NRVD from 1990 to 2021, this study projects future changes in the NRVD burden for the global level, China, the US, the CAR, and India from 2022 to 2040 (Figures 7,8 and Figure S3). Results indicate declining trends in both NRVD-associated mortality and DALYs, with India projected to experience a relatively limited reduction. Regarding incidence, NRVD cases are expected to steadily decline globally, in the US, and in the CAR, while China and India show a steady upward trend.

Figure 7 Projected trends in the ASMR of NRVD from 2022 to 2040, with 95% UI, for the Global population, US, CAR, China, and India. ASMR, age-standardized mortality rate; CAR, Central African Republic; NRVD, non-rheumatic valvular disease; UI, uncertainty interval; US, United States.

Figure 8 Projected trends in the ASIR of NRVD from 2022 to 2040, with 95% UI, for the Global population, US, CAR, China, and India. ASIR, age-standardized incidence rate; CAR, Central African Republic; NRVD, non-rheumatic valvular disease; UI, uncertainty interval; US, United States.

Discussion

This GBD study systematically assessed the epidemiology of NRVD across four representative countries. Analyses indicated that the global burden of NRVD increased 2.1-fold since 1990. CAVD demonstrated the highest mortality burden among NRVD subtypes during the study period. Substantial cross-country disparities emerged: the US maintained the highest incidence and mortality rates among studied nations; China recorded both the highest DMVD incidence and the most rapid ASIR growth; the CAR exhibited low incidence yet disproportionately high mortality; while India showed low baseline incidence with divergent mortality trajectory (increasing rather than decreasing). Projections through 2040 suggest a continued decline in both the ASMR and age-standardized DALYs rate rates associated with NRVD; however, the incidence rates of NRVD in China and India are projected to rise.

A global assessment of the burden of NRVD revealed that high Socio-demographic Index (SDI) regions exhibited the highest morbidity and mortality rates (16), a finding corroborated by this study. Among the four countries analyzed, the US demonstrated the greatest NRVD-related disease burden, likely due to the reduced influence of competing mortality risks—particularly in high-SDI settings, where other causes of premature death are less prevalent (17). In these regions, the lower incidence of midlife and early-adult mortality from common conditions increases the likelihood of survival into older age, thereby unmasking the burden of degenerative valvular disease associated with aging (17). The US benefits from a well-developed health insurance system that facilitates routine health screenings, thereby enhancing the detection of asymptomatic valvular lesions (18). Concurrently, population aging contributes to an increased burden of degenerative valvular disease (19). This study observed that mortality rates for CAVD in the US remained stable until 2015 but subsequently declined—a trend likely attributable to the approval and adoption of transcatheter aortic valve replacement (TAVR) beginning in 2012 (20-22). According to the most recent STS/ACC TVT Registry data, 54,782 patients underwent TAVR in the US between 2012 and December 2015, with significant reductions in both in-hospital mortality (from 5.7% to 2.9%) and 1-year mortality (from 25.8% to 21.6%) (23). China exhibits a distinct “high incidence-low mortality” pattern in NRVD epidemiology. The ASIR is increasing at 4.6 times the global rate, while the ASMR remains at just 3.3% of US levels and continues to decline. This trend contrasts sharply with the increasing ASMR observed in middle- and high-income countries (EAPC: +0.43%) reported in prior studies (16). The favorable mortality trend may be partially attributable to the exceptional outcomes of TAVR in Chinese patients with non-rheumatic aortic valve disease, particularly those with bicuspid aortic valve (BAV). Recent data demonstrate a hospitalization mortality rate of just 2.2% (as low as 1.4% for BAV cases) and an impressive 1-year survival rate of 95.5%, significantly outperforming conventional surgical approaches (24). The rising prevalence of hypertension in China—reaching 27.5% among adults aged ≥18 years by 2021 (25)—has positioned DMVD as the predominant valvular subtype, accounting for 81.3% of cases. This epidemiological shift carries significant implications, as DMVD is associated with lower mortality risk compared to CAVD (11). Notably, CAVD has exhibited a rising incidence alongside a declining mortality rate—a trend that reflects further advancements in healthcare technology within China. This pattern may be attributed to enhanced diagnostic capabilities, improved early detection, and more effective treatment modalities, which collectively contribute to better patient outcomes despite the increasing detection of cases. While primary and secondary prevention could effectively manage most valvular diseases, inadequate implementation of these measures in Africa contributes to persistently elevated mortality rates (26). A large single-center study involving 136,908 patients undergoing their first echocardiogram in India revealed that RHD remains the predominant form of VHD (27). This persistent pattern reflects India’s demographic profile—characterized by a younger population and lower life expectancy (28), which has delayed the epidemiological transition toward calcific AS as a primary cause of valvular morbidity and mortality. While previous studies projected that NRVD mortality in low- and middle-income countries (LMICs) would decline with economic development (16), our findings demonstrate an opposing trend in India. From 1990 to 2021, the ASMR for NRVD increased at an average annual rate of +0.39%, culminating in a 20% mortality increase compared to 1990 baseline levels. This paradoxical rise may be attributed to several factors: (I) the high prevalence of RHD may accelerate NRVD progression through valvular damage mechanisms; (II) the substantial proportion of CAVD deaths occurring without adequate treatment access; and (III) limited availability of TAVR and ineffective management of degenerative valve lesions.

Sex and age are significant determinants of NRVD. GBD epidemiological data reveal that, across countries stratified by all four World Bank income groups, ASIRs are typically higher in men than in women. However, postmenopausal women exhibit a higher risk of developing NRVD than men. This pattern of heightened risk among postmenopausal women mirrors the well-established gender differences observed in cardiovascular disease research (29). This differential susceptibility may be attributed to distinct biological mechanisms: males exhibit greater vulnerability to calcific lesions, potentially driven by androgen-mediated promotion of valvular calcification and osteogenic differentiation. Conversely, estrogen provides protection in females by delaying calcification; however, this protective effect diminishes after menopause, leading to accelerated fibrosis. These contrasting hormonal influences ultimately contribute to a sex-specific pathological phenotype in NRVD (30). Despite the higher prevalence of NRVD in men, women exhibit higher age-standardized rates of DALYs and mortality. This disparity may be associated with several factors: delayed healthcare-seeking behavior for symptoms among female patients (31), a higher prevalence of more severe AS, often associated with smaller valve sizes (32), lower levels of physical activity, greater exposure to familial caregiving responsibilities and associated psychosocial stress, and complications arising during pregnancy (33). China demonstrates a distinct male predominance in NRVD mortality that contrasts with global trends. This disparity may be associated with gender-specific risk factors, including high smoking prevalence among Chinese men (52%) (34) and poorer adherence to secondary prevention medications. The age distribution of NRVD burden in this study (peak 65–69 years) closely aligns with the 2019 GBD findings for China, India, and the US, confirming the characteristic aging-related pattern in middle- and high-income countries (16). In contrast, CAR shows a younger age at disease burden, likely reflecting both competing mortality risks and lower life expectancy in the region (19). Age is a well-established risk factor for NRVD, with disease likelihood doubling per decade of life (35,36). The rising global prevalence of NRVD parallels increasing life expectancy, reflecting its strong association with aging. Emerging evidence indicates that NRVD progression involves active pathological processes, including chronic systemic inflammation and oxidative stress, which are exacerbated by aging (37,38). The interplay between fibrocalcific remodeling and inflammation in aortic valve disease further underscores the mechanistic complexity of NRVD (39). Given the poor prognosis of elderly patients with NRVD and ongoing global population aging, developing targeted prevention and management strategies represents an urgent public health priority.

Several nations have implemented targeted public health initiatives to address NRVD. The US, bearing a substantial burden of CAVD, has adopted comprehensive measures, including the incorporation of echocardiography in routine physical examinations for adults aged ≥65 years through the Heart Valve Disease Screening Program, along with dietary modifications guided by the FDA’s nutritional labeling system to reduce consumption of high-cholesterol foods (40). These interventions have demonstrably improved cardiovascular health outcomes. Advances in diagnostic technology are emerging. Tandon et al. (41) demonstrated the clinical potential of multiphoton microscopy for noninvasive early detection of CAVD, facilitating precision medicine approaches. While these strategies have contributed to declining age-adjusted morbidity rates in the US, their current focus remains predominantly on age-related degenerative valvulopathies. This model proves particularly relevant for developed nations with robust healthcare infrastructure and disease profiles dominated by degenerative conditions. India leverages telemedicine as a tool for delivering healthcare in rural areas. Under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), it subsidizes heart valve surgeries for impoverished populations. Concurrently, the mobile clinical decision support system, developed by Arvind Raghu’s team, integrates the World Health Organization/International Society of Hypertension (WHO/ISH) risk prediction model with local guidelines (42). This system, combined with a telemedicine network empowering grassroots health workers (43), forms a trinity of policy, technology, and service in prevention and control strategies. This approach aligns with resource-constrained national conditions and holds high potential for replication and scaling. However, India continues to bear a heavy burden of RHD. At this stage of economic development, healthcare must be prioritized through a dual-pronged strategy: increasing investment in preventable diseases while promoting new technologies like TAVR and MitraClip to address degenerative valve diseases. In contrast, Central Africa’s resource constraints necessitate continued focus on infectious disease control, with VHD—particularly non-rheumatic forms—receiving limited policy attention. The region currently depends on international support and basic preventive measures, with inadequate treatment infrastructure. Future priorities should include establishing screening pathways using portable echocardiography, training community health workers in primary detection, and strengthening regional medical centers through international partnerships for severe case management. China, as a representative of emerging economies, has implemented a comprehensive approach featuring the designation of heart valve devices as a national innovation priority to reduce import reliance; cost containment through centralized procurement and insurance coverage; and specialized programs targeting high-risk populations for non-rheumatic valvular disease. The “Healthy China 2030” initiative emphasizes implementing comprehensive strategies for chronic disease prevention and treatment, with particular focus on establishing demonstration zones (44). Preliminary outcomes from project areas demonstrate significant improvements in cardiovascular disease risk profiles: hypertension prevalence declined from 34.69% to 23.51%, diabetes prevalence decreased from 16.76% to 8.96%, and average life expectancy increased by 1.57 years (45).

Limitations: First, healthcare infrastructure deficiencies in underdeveloped regions may result in both misdiagnosis and underdiagnosis of valvular diseases, potentially leading to underestimation of disease burden in areas with weak surveillance systems. Second, the lack of clear differentiation between CAVD, DMVD, and other NRVDs—particularly in regions with high RHD prevalence—may have introduced classification errors in our analysis. Third, in settings with limited primary data, the GBD study’s compensatory estimation methods introduce substantial uncertainty to the results. Finally, our analysis could not account for specific metabolic risk factors, which may affect the completeness of the estimates.

Conclusions

NRVD represents a substantial global public health challenge and exhibits distinct epidemiological patterns across countries at varying economic development levels. Our analysis reveals that degenerative lesions predominantly characterize the NRVD burden in the US. In contrast, China and India demonstrate a mixed disease spectrum, encompassing both degenerative and metabolic etiologies. CAR remains predominantly affected by RHD within the VHD context. While global mortality and DALYs attributable to NRVD show a declining trend due to advances in screening and treatment, India continues to exhibit an upward trajectory in its mortality rate. Conversely, CAR presents a pattern of relatively lower morbidity yet disproportionately high mortality. Addressing the global NRVD burden requires enhanced public health awareness, strengthened policy support, and updated evidence-based treatment guidelines for optimized disease management. Critically, differentiated prevention and control strategies must be tailored to the distinct disease spectra prevalent in high-income countries (HICs) versus LMICs. Specifically, scaling up early screening programs and expanding access to valvular interventions in LMICs are essential to mitigate the future NRVD burden more effectively.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2025-1-53/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2025-1-53/prf

Funding: This study was funded by the Guangdong Provincial Medical Research Foundation (Project No. C2024069) and Guangdong Yiyang Healthcare Charity Foundation (No. JZ2025150).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2025-1-53/coif). All authors report that this study was funded by the Guangdong Provincial Medical Research Foundation (Project No. C2024069) and Guangdong Yiyang Healthcare Charity Foundation (No. JZ2025150). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. All GBD data were accessed and used in accordance with the terms and conditions set by the Institute for Health Metrics and Evaluation (IHME).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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