Pulmonary arterial hypertension (PAH) is a progressive disease characterized by increased pulmonary vascular resistance and altered right ventricular function and structure (1, 2). Patients with PAH typically experience shortness of breath, especially during activity, along with symptoms such as weakness, chest pain, swelling of the ankles or legs, and dizziness, which can eventually lead to death (3–6). Reportedly, approximately 1% of the global population suffers from PAH, which affects 10% of people over 65 years of age (7). Between 1990 and 2021, although the age-standardized incidence showed no significant change, the number of patients with PAH has increased by 81.5%, with a higher proportion in the elderly population (8). The Rotterdam Epidemiological Study of Hypertension reported higher incidence among elderly participants compared to younger patients (9). These findings indicate a growing disease burden of PAH in the elderly population, highlighting the need for greater attention to incidence and mortality trends among this demographic. However, comprehensive global studies focusing on the elderly remain limited, and systematic reports on incidence and mortality trends in elderly PAH patients are lacking.

The Global Burden of Disease (GBD) study, spearheaded by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, is widely recognized as one of the most comprehensive global epidemiological databases. It provides a robust framework for comparative assessments of morbidity and mortality across countries, regions, and globally, facilitating a nuanced understanding of disease distributions and trends (10, 11). Despite the significant advancements in our understanding of PAH distribution brought about by previous GBD studies, these investigations have predominantly focused on an overall perspective that encompasses all age groups (8). While these studies have documented global, regional, and national trends from 1990 to 2021, they are not without limitations. Specifically, data on the elderly population remain fragmented, and variations in methodology complicate cross-national comparisons and overall assessments. This fragmentation and methodological diversity hinder the development of a cohesive understanding of PAH’s impact on the elderly. Furthermore, existing research has insufficiently addressed the prediction of future disease burdens. This gap in predictive research introduces substantial uncertainty into addressing the healthcare demands arising from global population aging. As the global population continues to age, the need for accurate projections and targeted public health strategies becomes increasingly urgent.

This study aims to provide a comprehensive analysis of the epidemiological trends of PAH among adults aged 60 and older, utilizing data from the GBD database spanning from 1990 to 2021. The study will analyze global, regional, and national epidemiological data on PAH among adults aged 60 and older. Key disease burden indicators, including incidence rate, mortality rate, and disability-adjusted life years (DALYs), will be examined to identify detailed temporal and spatial trends. Additionally, building on established epidemiological data and trends, robust statistical projection models will be employed to forecast the incidence of PAH in this population through 2050. This study aims to support the development of targeted public health interventions and improve the management of PAH in aging populations globally.

This study provides a comprehensive analysis of the global burden of PAH among individuals aged 60 and older from 1990 to 2021 and projects trends through 2050. Key findings indicate that during this period, global PAH incidence, mortality, and DALYs increased by 130, 130, and 100%, respectively. By 2021, there were 15,622 new cases (incidence rate: 1.43 per 100,000 people; 95% UI: 0.97, 2.05), 15,443 deaths (mortality rate: 1.51 per 100,000 people; 95% UI: 1.15, 1.80), and 248,064 DALYs (DALY rate: 23.54 per 100,000 people; 95% UI: 18.07, 27.89) globally. The age-standardized incidence rate rose from 1.447 to 1.66 per 100,000 population. The disease burden is unevenly distributed globally, with regions of medium SDI bearing the heaviest burden. China reported the highest number of cases and deaths, while Zambia had the highest incidence rate. Projections using the BAPC model indicate that the burden of PAH in the elderly population will continue to rise through 2050: the number of new cases is expected to reach 31,383 (95% CI: 17604.40, 45162.56) with an incidence rate of 1.46 per 100,000, approximately 20,687 deaths, and 302,760 DALYs. These findings underscore PAH as a significant and growing public health challenge within an increasingly aging population.

PAH is a serious disease that profoundly impacts the quality of life in the elderly and imposes a heavy burden on healthcare systems (16). The stable or slightly declining age-standardized rates of incidence and DALYs (EAPC = −0.01 for incidence, −0.23 for DALYs) indicate that the increase in absolute burden is primarily driven by population aging, while per capita risk is modulated by other factors. Lower-than-expected mortality can be attributed to significant advances in therapeutic strategies over the past two decades, including the development of targeted therapies, effective risk management, combination therapies, and improved diagnostic techniques, which collectively have enhanced survival rates among PAH patients (17). The transient decline in incidence observed between 2015 and 2018 may reflect temporary shifts in diagnostic or coding practices, warranting further investigation.

The burden of PAH varies significantly across socio-demographic regions, with the highest burden observed in areas with moderate SDI in 2021. This aligns with the complex interplay between an aging population and potentially lagging healthcare infrastructure. Despite population aging, the overall incidence trend shows a slight decline, which may be attributable to significant advances in early detection, improved screening programs, and heightened clinical awareness. The adoption of new risk assessment tools has facilitated earlier diagnosis, enabling more effective therapeutic interventions (18). Furthermore, the use of multimodal therapies has contributed to reducing mortality associated with PAH (19, 20). In contrast, high SDI regions consistently exhibit the lowest incidence rates, likely due to better integrated care and access to advanced treatments. The declining trend in low SDI regions may reflect improved public health interventions, although the possibility of undiagnosed cases and data limitations cannot be ruled out in these areas. This is evidenced by the substantial diagnostic gap between HICs and LICs within the GBD database.

Variations in the disease burden of PAH across different SDI regions may be influenced by specific national health policies, healthcare accessibility, and the pace of population aging (21). Medium-SDI regions, experiencing rapid population aging, may have healthcare systems that are not yet fully equipped to manage complex chronic diseases like PAH (22). This can lead to high diagnosis rates but limited treatment capacity, thereby increasing the overall burden. In contrast, high SDI regions typically have stronger primary care systems and specialist referral networks, which facilitate early detection and management of PAH, thus controlling its progression (8). The declining trend in low SDI regions may reflect inadequate diagnostic capabilities. A PAH diagnosis requires meeting the “hemodynamic definition of pulmonary hypertension (PH),” excluding other causes of precapillary pulmonary hypertension, and satisfying clinical/classification criteria (23). Future research should integrate specific national health policies and healthcare resource allocation to better understand the structural drivers behind these SDI disparities.

At the national level, China reported the highest number of pulmonary arterial hypertension (PAH) cases and deaths, consistent with its large and aging population. Zambia had the highest incidence rate, potentially linked to specific environmental or genetic risk factors. The significant increase in incidence in Slovakia and the marked rise in mortality in Latvia highlight the need for further investigation into local risk factors and healthcare system performance.

Projections using the BAPC model indicate that the burden of PAH in the elderly population will continue to rise through 2050. The highest incidence is projected for the 75–79 age group, while the highest mortality is anticipated in the 95+ age cohort. Increased stiffness in the cardiac and pulmonary vascular systems among the elderly elevates the risk of developing PAH (24). This underscores the need for age-specific prevention and care strategies in the context of accelerating global population aging (25).

From a gender perspective, women exhibit higher incidence, mortality, and DALYs rates than men across most age groups, particularly among those aged 60 and older. Previous studies have shown that the Y chromosome exerts a protective effect in hypoxia-induced PAH, reducing right ventricular systolic pressure and pulmonary vascular remodelling (26). It has been hypothesized that genes such as SRY and UTY may confer protection against PAH by enhancing BMP signalling and reducing proinflammatory cytokines (27, 28). However, with advancing age, the gradual loss of Y chromosome fragments in male peripheral cells or reduced expression of Y chromosome protective genes may diminish this protective effect, contributing to increased disease incidence in older males (29, 30). Conversely, estradiol has demonstrated bidirectional effects in PAH (the estrogen paradox), which may also contribute to the observed gender differences (31). Additionally, women tend to be more sensitive to early symptoms, such as shortness of breath, and are more likely to seek medical care promptly, which facilitates earlier diagnosis (32). In contrast, elderly men often attribute such symptoms to aging or comorbidities, resulting in delayed medical consultations and underdiagnosis. This disparity is further amplified by unequal access to healthcare resources. In regions with a high to medium-SDI, women achieve higher diagnosis rates due to easier access to regular check-ups. In regions with a low-SDI, some women still receive diagnoses despite widespread diagnostic limitations, while male patients remain entirely undiagnosed due to their near-total avoidance of medical care. Therefore, addressing this issue requires biomedical interventions and the implementation of gender-sensitive strategies, such as proactive screening of high-risk males, to address all contributing factors comprehensively.

Using GBD 2021, we provide a systematic, global snapshot of PAH in adults aged greater than 60 years. Our findings show that the burden is highest in middle-SDI countries; China contributes the largest absolute number of cases, while Zambia records the highest age-standardized incidence; older women consistently face greater risk than men. These epidemiological insights offer immediate, location-specific targets, such as intensified screening in middle-SDI settings and sex-tailored management for elderly women. Additionally, our BAPC projections provide actionable foresight for health-system planning toward 2050, when one in six people worldwide will be over 65.

However, this study has several limitations. The GBD estimates we used can under- or overstate true rates due to weak death registration and patchy diagnostic capacity in many low- and middle-income countries. The GBD also lacks data on air pollution, smoking, drug use, or local access to care, limiting our ability to explain why rates rise or fall in specific places. The absence of individual-level information means we cannot adjust for genetic background, comorbidities, or treatment adherence, and the clinical meaning of the estimates is limited. These data issues directly affect our trend tests. The UI provided by GBD is designed for single-year comparisons, not for tracking changes over time. We used non-overlapping UI to judge differences, but this approach ignores the serial correlation in time series and may inflate false positives. Joinpoint results depend on user choices, such as minimum observations per segment and maximum number of joinpoints, which can alter conclusions about recent trends. The EAPC assumes a constant log-linear slope from 1990 to 2021, averaging out any plateaus, rebounds, or declines, which may misrepresent trends as “stable” when they are not. For the 2050 projections, the BAPC model assumes that age, period, and cohort effects observed in only six five-year periods will remain unchanged for the next 29 years. The coarse age groups (eight five-year bands above 60) and thirteen ten-year birth cohorts smooth out shocks such as war or drug-era fluctuations, likely overstating forecast precision. Finally, our curve fitting between SDI and PAH burden uses an ecological composite index tied to the same social variables that shape healthcare access; the association is descriptive and cannot be taken as causal.

This study highlights the substantial and growing burden of PAH among the global elderly population, with a disproportionate impact on female and middle-SDI countries. Projections indicate a marked escalation by 2050, although these estimates assume stable trends and should be viewed with caution. The findings underscore the urgent need for targeted public health strategies, including enhanced early detection, sex-specific management, and stronger data systems, to mitigate PAH’s impact in an aging world.