Divergent Cardiovascular Disease Burden in Hungary and Iraq: A Comparative Analysis of Global Burden of Disease Estimates
Abstract
Background/objective: Cardiovascular disease (CVD) remains a major cause of death in Hungary and Iraq, which differ markedly in demographic structure, socioeconomic context, and health-system capacity. This study compared annual age-standardized cardiovascular mortality and incidence in Hungary and Iraq from 1990 to 2023 and examined selected risk-attributable cardiovascular mortality trajectories. Methods: The analyzed Global Burden of Disease (GBD) 2023 estimates for both sexes were used with annual age-standardized rates per 100,000 population. The primary temporal analysis used restricted cubic splines (RCS) for calendar year with four knots at the 5th, 35th, 65th and 95th percentiles, country effects, and country-by-spline interactions. Feasible generalized least squares with within-country AR (1) correlation were used to account for serial dependence. Selected-year predictions were obtained for 1990, 2000, 2010, 2020, and 2023. Risk-factor analyses were exploratory and limited to six prespecified country–risk pairs. Results: Age-standardized CVD mortality declined by 45.7% in Hungary and 21.1% in Iraq from 1990 to 2023, while age-standardized incidence declined by 43.9% and 15.4%, respectively. In 2023, CVD mortality was 289.2 per 100,000 in Hungary and 429.7 in Iraq, while incidence was 620.1 and 808.6 per 100,000, respectively. RCS analyses showed substantial non-linearity and country-specific trajectories for both mortality and incidence (all joint tests p < 0.001). In Hungary, attributable mortality rates declined for smoking, high LDL cholesterol, and air pollution; in Iraq, the BMI-attributable rate increased, while the fasting-plasma-glucose and high-systolic-blood-pressure trajectories showed more complex changes. Conclusions: Hungary and Iraq carry substantial but structurally different cardiovascular burdens. Iraq had the higher age-standardized CVD mortality and incidence in 2023, while Hungary experienced larger long-term declines. The trajectories indicate that cross-country differences reflect changing patterns of incident disease and risk-attributable burden rather than a single constant trend.