Structural heart disease burden and trends in working-age adults across G20 Countries, 1990–2021: a GBD 2021 analysis with risk prioritization

Background: Structural heart diseases (SHDs), including rheumatic and non-rheumatic valvular diseases, cardiomyopathy, and congenital anomalies, remain a significant cause of morbidity and mortality worldwide. Their impact on the working-age population is often underrecognized, particularly in middle- and high-income countries undergoing rapid lifestyle and industrial transitions. Methods: Data were obtained from the Global Burden of Disease (GBD) 2021 study for all G20 countries. The analysis included deaths, disability-adjusted life years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) among adults aged 15–64 years from 1990 to 2021. Temporal trends were assessed using the estimated annual percentage change (EAPC). Risk exposure was evaluated through the Summary Exposure Value (SEV) for major cardiovascular risk factors. Least absolute shrinkage and selection operator (LASSO) and Extreme Gradient Boosting (XGBoost) were used to prioritize determinants of SHD burden. Results: In 2021, SHD burden varied widely across G20 countries. The highest DALY rates were observed in India, South Africa, and Russia, mainly due to rheumatic and alcoholic cardiomyopathies, whereas high-income countries had a lower fatal burden but a greater share of non-fatal valvular disease. From 1990 to 2021, rheumatic heart disease declined steadily across most countries (EAPC < 0), whereas alcoholic and non-rheumatic cardiomyopathies showed heterogeneous or rising trends. Between 2019 and 2021, SHD-related deaths and DALYs fell by approximately 2% in both sexes. LASSO and XGBoost analyses identified high systolic blood pressure, elevated BMI, dietary sodium intake, air pollution, and occupational exposures (beryllium and sulfuric acid) as the dominant predictors of SHD burden. Conclusions: Among working-age populations in G20 countries, the burden of SHD is shifting from infection-driven to metabolic, behavioral, and occupational causes. Effective prevention requires integrated strategies addressing hypertension, obesity, dietary risks, air quality, and workplace safety to reduce premature mortality and disability in the global workforce.