Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality, inflicting substantial social and economic costs (1, 2). According to the Global Burden of Disease (GBD) 2021 study and the World Heart Report 2023, CVDs are responsible for 20.5 million deaths globally, accounting for approximately one-third of total deaths (3, 4). The Asia exhibits tremendous disparities and adversities in wealth status, rendering it a critical focal point for CVDs prevention and control efforts. According to the China Cardiovascular Health and Disease Report 2023, CVDs serve as the leading cause of death, accounting for 48.980% of deaths in rural areas and 47.350% in urban regions in 2021 (5, 6).

CVDs mainly appear in the middle-age adults and older adults. CVDs in adults encompass a range of disorders affecting the blood vessels, including coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD). However, some CVDs tend to be triggered in younger population in recent decades. For example, the prevalence of hypertension in youths in China was 13.000% in 2019, 13.200% in girls (12.700% in boys), also 14.100% in the rural (11.900% in the urban), representing an upward trend with age (7).

As a major cause of CVDs mortality in youths in developing countries, rheumatic heart disease can cause approximately 250,000 deaths every year and reaches a peak between the 20–29 age. DALYs for alcoholic cardiomyopathy rises rapidly from the age of 25 (8). Moreover, infective endocarditis in youths without congenital heart disease was really similar to that in adults and caused short-term deaths, combined with acute heart failure, compared with those with congenital heart disease (9, 10).

CVDs in youths present chronic and complex conditions inflicted by biological contexts and environmental factors (7). Adolescence is an important period for physical and mental development being more neglected for health coverage (11, 12). Previous studies suggested that CVDs in youths presented a substantial share in mortality burden with that of adults (13). Atherosclerosis can begin early in lifetime and develop undetected for an extended time before going into an advanced phase with clinically presentable manifestations (14, 15). The underlying mechanisms and features of pediatric CVDs exhibit specific patterns and differ commonly compared with adults (6, 16). Most importantly, the pathological changes from childhood to adulthood can predict fatal or nonfatal CVD in later middle lifetime.

Obesity, high blood pressure, and abnormal plasma lipids are well-established CVDs risk factors appearing in childhood and adolescents (17). If these risk factors, being inherited or acquired, continue to be unmodified, high-risk conditions are prone to develop the adverse outcomes when approaching adults. Previous research focuses on clinical factors such as obesity, blood pressure, and cholesterol that align with CVDs in adults, while researches on pediatric CVDs tend to focus on lifestyle-related factor, such as dietary quality, physical activity and psychological characteristics (18). Critical barriers to early prevention are the difficulty in accurately evaluating CVDs risk in youths due to the subclinical nature of CVDs. Evidence on potential risk factors for CVDs among young population globally is limited. These gaps might be involved in informing effective strategies and prevention efforts to reduce CVDs burden in young population worldwide.

There is an urgent need to develop and implement effective and targeted strategies for the primary prevention of CVDs. Understanding the temporal trends in the epidemiological trends of overall CVDs in youths and its attributable risk factors is crucial worldwide. To the best of our knowledge, the features of CVDs epidemics in the young population across the world have yet to be presented, also a comprehensive profile in Asia and China. Therefore, we aimed to report CVDs epidemics and burdens and how they changed from 1990 to 2021 using newly updated estimates of total and specific CVDs in young population aged 0–19 at global, regional, and national levels, stratified by age, sex, regions, countries, and sociodemographic index (SDI), also along with predictions to the 2036 year.

In 2021, the number of CVDs among children and adolescents were 20.928 million (95%CI: 16.652–25.860) globally, 8.862 million (95%CI: 7.018–10.910) in Asia, and 2.131 million (95%CI: 1.697–2.667) in China, with prevalence rate of 794.020 (95%CI: 631.780–981.130), 614.030 (95%CI: 486.320–755.900), 637.670 (95%CI: 507.670–797.820) per 100,000 population, respectively. While metrics showed downward trends (all AAPC <0), excepted for four exceptions: global incidence (0.314, 95%CI: 0.271–0.357), global prevalence (0.506, 95%CI: 0.439–0.574), global YLDs (0.203, 95%CI: 0.172–0.234), and Asian prevalence (0.163, 95%CI: 0.080–0.245) (Table 1).

Figure 1 mapped the global CVDs burden for children and adolescents synthetically. Briefly, DALY rates were predominantly concentrated in African in both 1990 and 2021. In 2021, the three highest DALY rates were in Republic of Niue: 1513.120 (95%CI: 1336.220–1721.500); Tokelau: 1371.700 (95%CI: 1055.120–1624.180); State of Libya: 1264.530 (95%CI: 986.530–1600.860) per 100,000 population, respectively. Conversely, the lowest DALY rates predominantly clustered in high-SDI nations: Republic of Cyprus: 42.600 (95%CI: 35.300–51.420); State of Israel: 42.610 (95%CI: 36.040–51.050); Swiss Confederation:45.090 (95%CI: 38.350–53.070). A strong inverse correlation linking higher SDI with lower DALYs rates existed (Supplementary Figures 1, 2).

Our study used the best available and robust estimates from the GBD 2021 to explicitly report CVDs epidemics and burden in children and adolescents. In the past three decades, CVDs burden still presented a substantial decline across the world, but it is projected to increase to 2036. Also, a critical public health paradox existed: fatal metrics (mortality and YLLs) have declined significantly, while non-fatal metrics (prevalence and YLDs) have risen substantially. This divergence underscores an ongoing epidemiological transition in pediatric CVDs, that is, from acute and fatal manifestations toward chronic and disabling conditions requiring long-term attention and management.

In terms of births number, China and some Asian countries are experiencing the most significant declining trend (23). This demographic shift may, to some extent, influence the evaluation of the disease epidemic. However, some indicators, including mortality and DALYs, presented the downward trends, aligning with advancements in pediatric healthcare and precision prevention worldwide. The results highlight the urgent need for better understanding of the mediators of cardiometabolic dysfunction in youths for prevention strategies of CVDs in early life. Moreover, the incidence, prevalence and YLDs indicators were higher for females than males, while the other three indicators (mortality, YLLs, and DALYs) showed the opposite direction worldwide. Females also presented a more pronounced decline in AAPC for mortality, YLLs, and DALYs compared to male counterparts. These disparities could be attributable to the combination of physiological properties, daily lifestyle and healthcare-seeking behaviors (24). Those social factors, such as military service participation and sports engagement for males, even enlarge the disparities in CVDs manifestations between genders. Consideration of gender differences is important for prevention, diagnosis, treatment and management of CVDs even for youngsters. The observed characteristics of the epidemics in different regions are of long-term importance, not only in guiding current national policies and strategies in CVDs prevention, but also in predicting future challenges.

In our study, negative associations between SDI and key metrics (DALYs, mortality, and YLLs) for children and adolescents reinforce the evidence that links socioeconomic status with CVDs epidemics, which highlights the imperative of taking actions to address the unique needs of this vulnerable population. Previous studies suggest that low-SDI regions exhibit disproportionately contributions to CVDs mortality from household air pollution (18.480% vs. 0.090%) and lead exposure (2.570% vs. 0.360%) compared with high-SDI regions (4, 19). Targeted interventions for disadvantaged populations through enhancing maternal health and early time nutritional state are essential to prevent CVDs for kids (25–27). Also, RHD and stroke have remained the key contributions to CVDs burden in this young population. Meanwhile, high systolic blood pressure and non-optimal temperature have emerged as critical risk factors for pediatric CVDs (1, 7). Future researches are needed to prioritize accessibility and equality of health workers and parental practices to promote health dynamics.

The global epidemic of childhood obesity and its precipitous upsurge have led to the emergence of CVDs in youngsters, including “adult-onset” diseases at an early age (28). Notably, most children are born with Ideal Cardiovascular Health (ICVH) with specific genetic conditions. The loss of ICVH is a gradual and continuous process, often preceded by prolonged, asymptomatic periods characterized by subclinical changes that eventually manifest as CVDs (29). Approximately 80% of overweight children aged 10–15 develop obesity as approaching adults, perpetuating cardiometabolic risks across the lifespan. Maternal health during lactation and early-life nutritional intake shape the trajectories of CVDs development (30). Early-life interventions, including maternal nutrition optimization and prenatal screening for fetal CVDs risks could prevent the development of CVDs (16). Such measures are vital to further reduce the disease burden in low-resource settings, where disparities in healthcare access exacerbate the burden of non-fatal outcomes. The medical advancements in treating CVDs have not been paralleled in adolescents and young adults, highlighting an urgent need to enhance the management of CVDs in this population, particularly in low-income countries. As for absolute case numbers trajectories of the CVDs epidemiologic transition, the future pattern remain stable, while prediction model to 2036 for the prevalence presents the declining trend as expected. The pathogenesis of CVDs originating in childhood could progressively worsen without timely interventions. Most importantly, monitoring the CVDs burden and promoting the progress in the availability of effective and safe prevention strategies worldwide are really important at early time.

However, this study has several limitations need to be considered. First, as civil registration systems serve as primary sources for mortality statistics, population coverage remains insufficient, especially in those low and middle-income countries. Incomplete medically reporting systems may compromise the quality and the representativeness of CVDs-related mortality data. Second, as children and adolescents CVDs exhibited complex factors with psychological adversity and nutritional factors, these dimensions could not be systematically evaluated due to the unavailability of the data. Moreover, the original data sources from specific countries and periods might influence the accuracy of the GBD estimates and account for the quality of the predictive models (19, 22, 31, 32). Countries and regions with scarce input data should establish high quality databases to help conduct more comprehensive and rigorous research.

In summary, the CVDs burden among children and adolescents is the continuously decreasing feature across the world during the last three decades and continues to rise up to 2036. The burden of overall and type-specific CVDs varied by age, sex, SDI, region, and country, and the marked geographic differences in CVDs epidemics are due to the combined effects of age and other determinants. Given the necessity of devising timely strategies to prevent and control CVDs, concerted efforts of the health workforce in the targeted implementation of effective primary prevention strategies to mitigate the disease burden.