Analysis of the International, Regional, and National Endocarditis-Related Disease Burdens (1990-2021), and Changes to Projections for the Next 15 Years: A Population-Based Study

Abstract

Background: Endocarditis can lead to health loss and even death, making it one of the major contributors to the global disease burden, with its incidence continuously increasing. This study aimed to assess the trends and frontier analysis of the worldwide burden of endocarditis over the past 30 years and to improve the predictions of its future burden by 2035.

Methods: We analyzed the trends of global endocarditis incidence, prevalence, deaths, and disability-adjusted life years (DALYs) at international, regional, and national levels from 1990 to 2021 using a comprehensive, localized, and multidimensional approach. Clustering analysis assessed the changing patterns of disease burden related to endocarditis in the Global Burden of Disease (GBD) study regions. Correlation analysis was conducted to determine the potential relationships between the burden of endocarditis and the socio-demographic index (SDI) and the Human Development Index (HDI). Frontier analysis was performed to identify possible areas for improvement and the disparities in development status among countries. Additionally, we projected the changes in the burden of endocarditis by 2035.

Results: From a global perspective, between 1990 and 2021, the incidence, prevalence, mortality, and DALYs associated with endocarditis have shown a continuous upward trend. At the national level, significant differences were observed in the incidence, prevalence, mortality, and DALYs of endocarditis worldwide. The United States had the highest number of deaths; India had the highest number of DALYs; Thailand had the highest incidence; Sri Lanka had the highest prevalence. The age-standardized rates (ASRs) for endocarditis prevalence, incidence, mortality, and DALYs increased steadily with age, peaking in the 95-year-old and above age group. The incidence, prevalence, mortality, and DALYs for males were 1.27 times, 1.02 times, 1.06 times, and 1.37 times those of females, respectively. Clustering analysis results indicated a significant increase in the estimated annual percentage change (EAPC) of mortality and DALY rates for endocarditis in East Asia. A significant correlation exists between EAPC and the ASRs of disease burden. Frontier analysis showed that countries and regions with higher SDIs have greater potential for improving the disease burden. The Bayesian age-period-cohort (BAPC) results indicated that the incidence, prevalence, mortality, and DALYs case numbers are expected to increase, with the ASRs for incidence and prevalence also projected to show a continuous upward trend by 2035.

Conclusions: The global burden of endocarditis, a significant public health issue, has shown an overall upward trend from 1990 to 2021. The continuous increase in the prevalence and incidence of endocarditis, driven by population growth and aging, has become a major challenge for its control and management, which may guide better public health policy formulation and the rational allocation of medical resources. This targeted approach is crucial for effectively alleviating the burden of this disease.

Keywords: GBD; deaths; disability-adjusted life-years; disease burden; endocarditis; incidence; prevalence.

Fig. 1.

The age-standardized rates (ASRs) (A) and total number of cases (B) of incidence, prevalence, deaths, and disability-adjusted life years (DALYs) for endocarditis in Global Burden of Disease (GBD) regions in 2021. (A) Displays the ASRs for different GBD regions, including incidence, prevalence, deaths, and DALYs. Incidence: Incidence rates are higher in high-income regions and advanced health system areas, while lower in some low-income regions, such as sub-Saharan Africa. Prevalence: Prevalence rates are significantly higher in developed regions, such as North America, Europe, and Central Asia, reflecting the accumulation of chronic cases. Deaths: Death rates are relatively lower in developed regions. DALYs: The DALY burden is higher in resource-limited regions, such as sub-Saharan Africa, South Asia, and Central Africa, while it is lower in high-income regions. (B) Shows the total number of cases of endocarditis in different GBD regions, including incidence, prevalence, deaths, and DALYs. Incidence cases: The number of incidence cases is higher in high-income regions and populous regions, such as Asia. Prevalence cases: Prevalence cases are more numerous in advanced health systems and high-income regions, reflecting higher diagnostic levels and chronic case management. Death cases: Death cases are more prominent in high-income regions, likely due to higher diagnostic rates and the burden of disease among aging populations. DALY cases: The DALY burden is predominantly concentrated in resource-poor regions such as Central Africa and South Asia, while it is relatively smaller in high-income regions. WB, World Bank.

Fig. 2.

Results of a cluster analysis based on estimated annual percentage change (EAPC) values for age-standardized mortality and disability-adjusted life years (DALYs) associated with endocarditis from 1990 to 2021. Color Classification: Different colors represent the trend in EAPC values across regions: Dark Red (minor increase): Regions with a minor increase, such as South Asia, the Americas, North America, and Latin America & the Caribbean. Blue (remained stable or minor decrease): Regions that remained stable or experienced a minor decrease, including Commonwealth high-income countries, the European Region, and Europe & Central Asia. Orange (significant decrease): Regions with a significant decrease, such as Central Africa, Western Africa, sub-Saharan Africa, Southeast Asia, and South Asia. Black (significant increase): Regions showing a significant increase, reflecting a worsening disease burden. Cluster Structure: Regions are grouped based on trends in EAPC values, illustrating the substantial variations in the burden of endocarditis mortality and DALYs across different socioeconomic settings. Summary: This figure highlights the diversity of trends in endocarditis-related mortality and DALY burdens across global regions from 1990 to 2021. WB, World Bank.

Fig. 3.

The global distribution of age-standardized rates (ASRs) and estimated annual percentage change (EAPC) for the burden of endocarditis by country and region in 2021, including incidence (A), prevalence (B), deaths (C), and disability-adjusted life years (DALYs) (D). (A) (Incidence): Displays the EAPC distribution of age-standardized incidence rates across countries and regions. Certain countries, such as Russia, show significant increases (red), while Northern Europe, parts of South America, and Africa demonstrate slight or negative growth. (B) (Prevalence): The global EAPC distribution of age-standardized prevalence rates shows an increasing trend in North America, Europe, and parts of the Middle East (blue and green), whereas some African countries exhibit a declining trend (red). (C) (Deaths): The EAPC distribution of age-standardized death rates reveals a significant decline in sub-Saharan Africa and Central Asia (green and blue). (D) (DALYs): The EAPC distribution of age-standardized DALY rates indicates an upward trend in certain countries, such as Russia (light green), while some African countries demonstrate a decline (blue).

Fig. 4.

Association between the estimated annual percentage change (EAPC) and age-standardized rates (ASRs) (A) as well as the Human Development Index (HDI) (B) for incidence, prevalence, deaths, and disability-adjusted life years (DALYs) of endocarditis in 2021. (A) (EAPC vs. ASR): Displays the association between EAPC and ASRs. Incidence and Prevalence: EAPC shows a positive correlation with ASR ($\rho$ = 0.52, $\rho$ = 0.51, p 0.01). Deaths: EAPC is positively correlated with ASR ($\rho$ = 0.23, p 0.01), but the correlation is weaker, indicating that changes in mortality are moderately related to baseline ASR. DALYs: EAPC has a weaker correlation with ASR ($\rho$ = 0.16, p = 0.03), suggesting a relatively minor relationship between changes in disease burden and ASR. (B) (EAPC vs. HDI): Displays the association between EAPC and the HDI. Incidence: EAPC is strongly positively correlated with HDI ($\rho$ = 0.72, p 0.01). Prevalence: EAPC shows a positive correlation with HDI ($\rho$ = 0.54, p 0.01). Deaths: EAPC is positively correlated with HDI ($\rho$ = 0.50, p 0.01), with more noticeable changes in mortality rates observed in countries with higher HDI. DALYs: EAPC shows a positive correlation with HDI ($\rho$ = 0.44, p 0.01), indicating a stronger trend of annual changes in DALY burden in countries with higher HDI. Circle explanation: Each circle represents a country, and the size of the circle is proportional to the disease burden. The $\rho$ index and p-values were obtained from Spearman correlation analysis.

Fig. 5.

Frontier analysis based on DALY age-standardized rates from 1990 to 2021, particularly in 2019 SDI. (A,C,E,G) illustrate the frontier analysis based on ASR and SDI from 1990 to 2021. The color scale ranges from orange (1990) to light blue (2019). The black solid line depicts the boundary. (B,D,F,H) display the frontier analysis based on ASR and SDI for 2021. The black solid line indicates the boundary, with dots representing countries and regions. The top 15 countries and regions with the greatest effective differences are marked in black. Examples of frontier countries with low SDI (0.5) and low effective differences are marked in blue, while examples of countries and regions with high SDI ($>$0.85) and relatively high effective differences are marked in red. Red dots indicate a decline in ASR, whereas blue dots indicate an increase in ASR from 1990 to 2021. Abbreviations: DALYs, disability-adjusted life years; ASR, age- standardized rate; SDI, socio-demographic index.

Fig. 6.

Prediction analysis of the total number of cases (A) and age-standardized rates (ASRs) (B) for incidence, prevalence, deaths, and disability-adjusted life years (DALYs) of the burden of endocarditis. (A) (Total number of cases): Displays actual case numbers from 1990 to 2020 and predicts trends from 2021 to 2035. Incidence cases: The total number of cases shows a significant upward trend and is expected to continue increasing in the future. Prevalence cases: The number of cases continues to rise after 2020, reflecting the cumulative effect of chronic cases. Death cases: The number of deaths peaked around 2020 and is projected to decline slightly, although it will remain at relatively high levels. DALY cases: The total number of DALY cases is expected to decrease gradually after 2020, indicating a reduction in disease burden, although regional differences may persist. (B) (ASR): Shows historical trends from 1990 to 2020 and forecasts ASR from 2021 to 2035. Incidence: ASR exhibits a continuous upward trend and is projected to keep increasing. Prevalence: ASR rises steadily post-2020, indicating a growing disease burden. Deaths: ASR shows a declining trend and is expected to continue decreasing, reflecting improvements in treatment and care. DALYs: ASR is projected to continue declining after 2020, suggesting an overall alleviation of the disease burden.