Hypertensive heart disease (HHD) is a cardiac dysfunction caused by hypertension that has gradually become a major global health issue. Initially considered an adaptive response, HHD progression not only leads to structural and functional cardiac alterations but is also closely associated with complications such as heart failure, atrial fibrillation, and coronary artery disease. HHD has become the second leading cause of heart failure (HF) (1–4). According to the World Health Organization (WHO), hypertension is a prevalent chronic disease, yet global blood pressure control rates remain alarmingly low at only 32.5% among treated individuals, affecting the health of billions worldwide (3). Concurrently, hypertension prevalence increases significantly with age, affecting approximately 65% of adults aged 60–79 and about 80% of those aged 80 and above (5). As global aging accelerates, the proportion of elderly populations is rising significantly. In 1990, individuals aged 60 and above constituted 9.2% of the global population; by 2013, this proportion had increased to 11.7%, and it is projected to reach 21.1% by 2051 (6). As the world's second most populous nation, China faces a substantial hypertension burden. In 2021, it reported a staggering 245 million cases of hypertension, with a prevalence rate as high as 15%. However, less than 15% of affected individuals received adequate treatment (7, 8). Consequently, hypertension-induced heart disease (HHD) has become a significant public health concern among the elderly, particularly noteworthy against the backdrop of extended human life expectancy (9).

The dramatic shifts in dietary patterns and lifestyles during periods of rapid economic growth represent another major contributor to HHD. Studies indicate that elderly hypertensive patients with altered dietary habits, sedentary lifestyles, elevated BMI, and dyslipidemia face substantially higher risks of heart disease (10–12). Current diets predominantly consist of high-calorie, energy-dense foods, while lifestyles increasingly feature sedentary habits, reduced engagement in traditional labor-intensive activities, and declining physical activity levels. This has led to rising rates of overweight and obesity. Obesity and its associated risks are the primary drivers of the increasing incidence of hypertension, causing more deaths than any other cardiovascular risk factor (2). Despite significant improvements in the treatment and management of arterial hypertension over the past decades, the prevalence of HHD and its associated risk of heart failure continue to rise. This underscores that HHD remains a critical public health issue warranting high attention and priority. However, to date, the vast majority of research on HHD has focused on its pathogenesis and therapeutic approaches. Epidemiological studies can reveal the burden of HHD on human health from a macro perspective, providing evidence for strengthening public health at the national level, prudently allocating medical resources, and formulating health strategies.

Therefore, as the G20 is an international economic cooperation forum comprising both developed and developing nations, whose member countries account for approximately 85% of global GDP（Gross Domestic Product) and two-thirds of the world's population, it represents a group of nations that dominate the global economic and political landscape (13). This study aims to systematically evaluate the disease burden of HHD and its temporal trends in China and the G20 as a whole (including China) from 1990 to 2021. It analyzes the characteristics of disease burden within this significant group and forecasts the incidence and mortality trends of HHD in China over the next 30 years. Currently, comparative studies examining the HHD disease burden between China and other nations remain scarce. This lack of comparative research hinders China's ability to identify shortcomings in its health policies and practices while limiting its capacity to draw lessons from effective strategies and experiences of other countries. By comparing China with G20 nations, this study not only provides an opportunity to learn from successful strategies implemented by other G20 countries but also offers valuable insights for nations at similar stages of economic development (14).

Table 1 compares the burden of disease between China and G20 countries from 1990 to 2021, presenting case numbers, prevalence rates, mortality counts, ASPR, ASDR, DALYs, and AAPC. The associated 95% uncertainty intervals (UIs) are provided in parentheses.

This study systematically assessed the disease burden of hypertensive heart disease in China and G20 countries from 1990 to 2021 and projected trends for China over the next 30 years. First, despite China's significant achievements in reducing HHD's age-standardized prevalence rate (ASPR), age-standardized mortality rate (ASDR), and disability-adjusted years (DALYs) over the past 30 years, China's current ASIR and ASMR for HHD remain higher than the G20 average. Furthermore, the number of HHD cases and deaths in China has increased substantially, with the majority of patients being elderly. This phenomenon likely stems from China's substantial investments in HHD prevention and control over recent decades. However, China continues to face challenges posed by its large population base and severe aging trends. The decline in China's age-standardized HHD burden metrics likely stems from substantial investments over recent decades in widespread hypertension screening, health lifestyle guidance, and broad access to effective antihypertensive medications. Research indicates that combining physical activity with healthy dietary patterns significantly reduces hypertension risk, underscoring the importance of lifestyle interventions in prevention. Increasing physical activity and adopting healthy dietary patterns effectively lower hypertension risk; replacing 21 min of sedentary time with running or stair climbing significantly improves blood pressure (20, 21). However, the substantial rise in both morbidity and mortality cases highlights two key factors. On one hand, this likely reflects the profound impact of population aging. This means that even with controlled relative disease risks, the sheer size of the elderly population will sustain a heavy disease burden, placing continuous pressure on healthcare systems. On the other hand, advances in medical technology and heightened public health awareness have led to the diagnosis of milder symptoms, statistically contributing to the apparent increase in prevalence (22). It is evident that the burden of HHD in China remains significant, and preventing and controlling HHD continues to be crucial for ensuring a high-quality life for the people.

Second, China and G20 nations exhibit starkly divergent historical trajectories: China's burden metrics have generally declined, while G20 countries show overall stability or slight increases. During this period, China achieved significant reductions in age-standardized prevalence rates (ASPR), age-standardized mortality rates (ASDR), and disability-adjusted life years (DALY) rates, with average annual percentage changes (AAPC) of −0.44%, −2.61%, and −2.90%, respectively. This positive trend likely stems from China's sustained public health investments over the past three decades. These include nationwide hypertension screening programs, large-scale public health education promoting low-salt diets and active lifestyles, and expanded coverage and accessibility of essential antihypertensive drugs within the national medical insurance catalog (7, 23). Notably, the new round of healthcare system reforms initiated in 2009 reinforced the role of primary healthcare services in chronic disease management, profoundly impacting standardized hypertension management and thereby effectively controlling HHD (24). In contrast, the age-standardized prevalence rate (ASPR) of HHD across G20 nations, including China, showed a slight yet statistically significant upward trend (AAPC = 0.34%). This indicates that the disease burden of HHD remains unchecked in major global economies.Potential reasons are multifaceted. First, many G20 member states are experiencing a persistent rise in the prevalence of metabolic risk factors such as obesity and diabetes, which are key drivers of HHD (25). Second, despite advances in medical technology, awareness, treatment, and control rates for hypertension remain at an unsatisfactory plateau in some countries, particularly low- and middle-income members (26). Moreover, the global trend of population aging represents an underlying factor that cannot be overlooked. The absolute increase in the elderly population directly contributes to the accumulation of HHD cases. Regarding gender disparities, males consistently bear a higher disease burden, potentially linked to their greater exposure to behavioral risk factors such as smoking and alcohol consumption (27).

Joinpoint regression analysis further refines our understanding of historical trends. The brief upward inflection point in China's age-standardized mortality rate (ASMR) between 2007 and 2010 may be linked to improvements in medical diagnostics, enhanced cause-of-death registration systems, or shifts in risk factors among specific subgroups during this period, warranting further investigation. First, China's new round of healthcare system reforms launched in 2009 significantly enhanced primary care capabilities and cardiovascular disease diagnosis awareness, potentially leading to more accurate reporting of previously underrecognized HHD-related deaths (24). Second, the continuous refinement of China's national cause-of-death surveillance system during this period, with improvements in reporting quality and coverage, may inherently elevate reported mortality rates (28). This inflection point underscores the importance of distinguishing genuine epidemiological shifts from the impact of surveillance system advancements when interpreting long-term disease burden trends. The long-term, gradual rise in ASPR among G20 nations serves as a warning: globally, the prevalence of HHD risk factors—such as obesity, high-sodium diets, and sedentary lifestyles—may be offsetting or even reversing the benefits gained from medical advancements. This trend suggests that the fundamental solution to HHD lies in moving beyond clinical treatment alone to prioritize preventive strategies that integrate population-level lifestyle interventions with clinical care.

Finally, projections for the next three decades reveal a daunting challenge: China's HHD prevalence is expected to continue rising. Although mortality rates are projected to decline further, China will still face a substantial HHD disease burden over the next 30 years. The ARIMA model predicts that China's HHD prevalence will rise while mortality declines, revealing a core contradiction: advances in medical technology can effectively delay patient death (reducing ASDR) but struggle to reverse disease progression and incidence (leading to cumulative increases in ASPR). First, the cumulative rise in ASPR may stem from increased public health awareness and higher screening rates. The ease of home blood pressure monitoring has boosted diagnosis rates. Additionally, in the current digital era, rising prevalence of depression and anxiety may contribute to the rising HHD prevalence (29, 30). Moreover, while hypertension prevalence is rising in China, awareness, treatment, and control rates remain relatively low. Inadequate blood pressure management and reinforcement can damage cardiac structure and function, ultimately leading to hypertensive heart disease (23, 26). With population aging, this trend signals that China will face an increasingly large HHD patient population in the future, likely linked to population aging trends. It is estimated that by 2030, over one billion people will be classified as elderly, defined as those aged 65 and above (31). China's aging population is progressively intensifying; according to the Seventh National Population Census, the proportion of individuals aged 60 and above has already exceeded 18% (2). This will place greater strain on healthcare systems including increased demand for medical resources and the need to enhance the quality and accessibility of healthcare services. This study has several limitations. First, GBD data are inherently model-based estimates; despite rigorous methodology, they may be influenced by the quality of source data and modeling assumptions. Second, although the GBD methodology strives for standardization, differences among G20 countries in hypertension diagnostic criteria, cause-of-death coding practices, and the sophistication of health information systems may affect the precision of cross-national comparisons. Third, ARIMA forecasting primarily relies on inertial extrapolation of historical data, failing to anticipate potential future breakthroughs in technology or robust public health policy interventions. Fourth, this study primarily analyzes data at the national level, failing to reveal disparities in disease burden between urban and rural areas or across regions within China. Future research should conduct in-depth subnational analyses to guide more precise resource allocation. Additionally, as a member of the G20, China's data is included in the overall G20 statistics, which to some extent affects the independence of inter group comparisons. Future research could conduct in-depth comparative analyses between China and other G20 countries.

In summary, this study systematically assessed the disease burden of hypertensive heart disease (HHD) in China and the G20 as a whole by analyzing data from 1990 to 2021 and projecting future trends in China. Key findings indicate that despite China's significant achievements in reducing age-standardized prevalence rates (ASPR) and age-standardized mortality rates (ASDR) for HHD, the aging population has driven a continuous rise in the number of affected individuals. The current burden level remains higher than the G20 average. Unlike the slight upward trend in G20 prevalence rates, China exhibits a declining trajectory, the timing coincides with concurrent national public health initiatives such as large-scale hypertension screening, primary care reinforcement, and improved drug accessibility, suggesting that these combined measures may have produced positive effects. Projections indicate that China's HHD prevalence will continue to rise over the next 30 years, signaling that a large and growing population of chronic disease patients will place long-term pressure on the healthcare system. To address this formidable challenge, China must implement tailored integrated strategies. While advancing primary prevention of hypertension and strengthening risk factor control, it is imperative to significantly enhance primary healthcare systems and establish patient-centered, comprehensive management models for HHD chronic diseases. This approach will more effectively reduce the disease burden and improve population health levels (8).