1 Background

Cardiovascular Disease (CVD) remains the leading cause of mortality and morbidity worldwide. According to 2019 World Health Organization (WHO) statistics, CVD accounted for approximately 17.9 million deaths, representing 32%. CVD is also responsible for significant disability and deteriorating quality of life in affected persons, with a comparatively more substantial burden in low- and middle-income countries [1,2,3,4]. As the fourth largest nation by population, Indonesia was severely impacted by the increase in population aging, urbanization, and change in lifestyle. Previous national Studies show CVD caused by stroke and ischemic heart disease as major causes and burden at national level [5].

The Global Burden Disease (GBD) study is a collaborative multi-national research study that estimates the burden of multiple diseases and their contributing risk factors at the global, regional, and national levels. Research that analyzes the burden of cardiovascular disease has been conducted globally [6,7,32]. It has been predicted by the evolution of cardiovascular disease where pestilence and famine, common in low socioeconomic status, will move to degenerative man-made disease [26, 33]. Indonesia's significant change in Gross Domestic Product per capita from 1990 to 2019 ($582 vs. $4151) and reduction in extreme poverty percentage (62.8% vs. 4.4%) play a significant role in RHD and congenital heart disease reduction [34].

In general, CVD Age-Standardized DALYs Rate (ASDR) has remained stagnant for approximately 30 years (− 0.7% change). This contrasts with significant CVD ASDR decreases in global and Southeast Asia rates, indicating that Indonesia bears stubbornly high burden rates from increased premature mortality and years of living with disability [12, 35]. Although decreased DALY rates were recorded for RHD and CHD, this was balanced by DALY gains in non-communicable CVD rates. This is also shown by the stagnancy in progress of reducing premature death from non-communicable diseases in Indonesia. Several factors have contributed to this stagnancy, including CVD risk factors, primary and secondary prevention measures, socioeconomic status, health infrastructure, and a lack of health workers [36,37,38,39].

4.3 Gender Difference

Despite an overall rise in mortality and stagnant DALYs, there is a marked gender disparity in these trends. CVD mortality rates have increased by 20.3% in men compared to 3.6% in women, leading to a notable difference (357 vs. 416 per 100,000). The reported sex differences in CHD and stroke mortality align with studies showing men generally have higher mortality rates [35, 40]. The findings on sex differences in CVD risk from previous studies have been mixed, with varying results on which gender faces a higher risk. Differences in both behavior and healthcare utilization may influence the observed disparities between genders. Regarding behavioral risk factors, as illustrated in Fig. 6, the burden of CVD attributable to smoking show significantly higher in males, being up to 4.24 times greater than in females (2771 vs. 653). This further evidenced by recent study from WHO. Indonesia overall tobacco usage rates: 34.5% of the adult population (70.2 million adults) currently uses tobacco products (smoking, smokeless, or heated tobacco products), with a significant gender divide where 65.5% of men and only 3.3% of women are tobacco users [41].

Fig. 6
figure 6

Risk factors contributing to age-standardized cardiovascular disease DALYs rates in Southeast Asian countries. [Numbers in brackets indicate the percentage contribution of each risk factor to the total risk factors for each region and sex; red color indicates a higher percentage]

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Recent study also indicates that men are less likely to seek primary care compared to their female counterparts. This behavioral pattern may contribute to the observed disparities in health outcomes between genders [42, 43]. The lower number of men utilizing primary care services can be attributed to accessibility challenges, particularly for working-age males whose job schedules, predominantly in the morning, conflict with primary care operating hours. Compliance and adherence are important factors of chronic CVD management, and policymaker needs to adjust the preventive approach of primary care (i.e., add evening or weekend hours of primary care) [44, 45].

4.4 Variation in Provincial Level

Despite the stagnancies of total DALY, Indonesia has made commendable strides in curbing mortality and morbidity rates associated with congenital heart disease and rheumatic heart disease. This transformation signals a shift from infectious and maternal issues to chronic ailments predominantly observed in the elderly. This evolution can be attributed to enhanced child and maternal healthcare services. Simultaneously, Indonesia is undergoing a demographic transition with an increasing elderly population. Same pattern is shown in global and regional [46,47,48,49,50]. This trend is particularly evident in provinces with significant aging populations like West Nusa Tenggara and Central Java. Here, the disease pattern largely mirrors the national trend, with a notable exception for ailments like stroke, ischemic disease, and other chronic CVDs. These particular diseases have substantially increased in these provinces, indicating region-specific health challenges amidst the broader national progress [51].

4.5 Increase in Risk Factor of Cardiovascular Disease

The shifting CVD burden has been attributed to multiple factors, including economic, behavioral, demographic, health workforce, and health infrastructure factors. In terms of economic factors, the economy has grown over the last 30 years and caused a shift in CVD burden from a lower poorer economy (RHD) to a CVD burden in workers with increased incomes (IHD) [26, 27]. Regarding behavioral factors, high blood pressure and smoking are standard in Indonesia and are the primary causes of increased DALY rates. Fail on risk reduction is still the concern in Indonesia, where healthcare fails to make hypertension patients still on the cascade of care, and only 15% of patients with hypertension routinely control to primary healthcare [38, 52,53,54,55].

The GBD risk factor result has shown that hypertension is the leading cause of CVD, accounting for 36%–42% of all strokes and 20%–25% of all IHDs. Additionally, smoking in males led to a large proportion of IHD (25%) and stroke (17%). High blood cholesterol is also a significant risk factor for 17.8%–19% of IHD events and 10% of all ischemic strokes [52, 56,57,58]. Southeast Asia has one of the highest total cholesterol increases, with four countries implicated: Indonesia, Thailand, Malaysia, and Cambodia. Indonesia is one of the five countries with the highest number of adults with diabetes, accounting for 48% of all diabetes patients in the world [59]. It is also in the top ten countries with the highest number of deaths from high blood sugar [60, 61].

4.6 The Economic Impact of CVD Burden

The economic impact of cardiovascular disease (CVD) can be understood at the micro- and macro-levels [62]. On the macro-level, the economic burden is seen in the loss of productive years within the population. This includes premature deaths, quantified as Years of Life Lost (YLL), and the disability caused by the disease, measured as Years Lived with Disability (YLD). Reducing premature mortality due to CVD would improve health outcomes and maximize human capital productivity over an extended period [62,63,64,65]. In the specific context of Indonesia, which is experiencing economic growth, the aging population with a sustained burden of CVD presents a potential challenge. If the burden of CVD remains unaddressed, it could significantly hinder Indonesia's economic progress by increasing the cost of illness and reducing the maximum capabilities of human capital.

On the micro-level, it involves individuals' catastrophic health expenditure (CHE) in treating CVD. Studies have shown that NCD CHE increased with the NCD share of DALYs, especially for vulnerable populations [65, 66]. A Study from Vietnam explains that the burden is not only at the individual level but also at the household level. A family with one member older than 60 years old with CVD is likely to suffer and reduce the economic capabilities of all family members. This further may threaten Indonesia poverty reduction efforts [64].

4.7 The Limitations

While our research presents a broad view of the burden of cardiovascular diseases (CVDs) in Indonesia, it is essential to acknowledge its limitations. Notably, several references underscore the limitations of utilizing GBD data. It may have inherent biases and inaccuracies. Inaccuracy was common in estimating dates, and uncertainty measurements were needed. The 95% uncertainty interval (UI) is provided in the table. The range of uncertainty needs to be considered if it is too wide. This study also could not answer the disparities yet due to not investigating the socioeconomic status. However, given the comprehensiveness of GBD data and the absence of frailty estimates in many countries, this approach remains valuable for global frailty monitoring and comparison. As frailty gains recognition as a significant public health challenge, comparative estimates like those provided by GBD are increasingly essential for policymakers and healthcare planners. These estimates are particularly crucial in contexts where formal frailty assessment is unfeasible. They support effective policymaking and resource allocation, addressing public health challenges more specifically.

4.8 Recommendations for Future Research and Policymaker

Given the insights and limitations identified, future research has several directions. A deeper exploration into the underlying causes of the identified trends, especially in provinces like West Nusa Tenggara and Central Java, would be beneficial. Furthermore, there is a need for more comprehensive studies focusing on the gender disparities in CVD mortality and morbidity rates. Investigating the behavioral, socioeconomic, and cultural factors contributing to these disparities will provide a richer understanding.

Indonesia is shifting toward chronic care management to fight cardiovascular diseases (CVD), impacted by high systolic blood pressure, nutrition, and smoking. Our analysis shows they are key CVD factors. Indonesia has developed focused techniques to aggressively identify at-risk persons. Integrated NCD Community Care programs like Posbindu and Prolanis are implemented. However, make patient compliance to care still difficult. This emphasizes the necessity for evaluations to enhance healthcare delivery and patient commitment in chronic care. To reduce CVD risks, population-level interventions including taxes on high-salt and high-sugar items, tobacco tax and cessation programs, and infrastructure that promote physical activity are essential.

5 Conclusions

This study highlights Indonesia's burden change of cardiovascular diseases (CVD) over the past three decades, which contrasts with global trends. While RHD dramatically reduced, it highlights stroke and IHD as the primary contributors to the increase in CVD-related deaths and DALYs. Peripheral artery disease, often overlooked, also shows worrying trends. While Global Burden of Disease (GBD) estimates provide a broad view, the limitations inherent in this data source underscore the need for enhanced capabilities in Indonesia's national and provincial CVD registries and assessments to further become the basis of intervention.