INTRODUCTION

According to the 2023 data from Statistics Korea, cardiovascular disease (CVD) was the second leading cause of death among Koreans, following malignant neoplasms [1]. With the rapidly aging population, the prevention and management of CVD are becoming increasingly important public health concerns. While Korea has historically had lower CVD mortality rates than some other countries, and age-adjusted CVD mortality has declined, heart disease mortality has shown an increase in recent years [2]. Effective prevention and management of CVD require not only addressing the disease itself but also focusing on the control of its associated risk factors [3–7]. A large proportion of Korean adults have at least one CVD risk factor, with a significant number having multiple risk factors. According to research, 70% of Korean adults have at least one CVD risk factor, 41% have two or more, and 19% have three or more risk factors, including hypertension, diabetes, hypercholesterolemia, obesity, and smoking [8]. The prevalence of multiple risk factors increases significantly with age, with 65% of individuals over 70 having at least two risk factors and 34% having three or more [8]. Therefore, early detection of high-risk individuals for CVD and prompt management of chronic metabolic diseases and comorbidities are very important issues for the primary prevention of CVD.

This is the first fact sheet from the Korean Society of Cardio-cerebrovascular Disease Prevention summarizing the current status of CVD among Korean adults using Korea’s National Health Insurance Service (NHIS) database. It presents key statistics on major CVDs based on the most recent national data, including mortality rates, CVD incidence, and associated risk factors. This fact sheet aims to support evidence-based policymaking, healthcare planning, and public awareness in response to the growing burden of CVD in the Korean adult population.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of The Catholic University of Korea (No. VC24OISI0271). The requirement for informed consent from the study subjects was waived due to the retrospective study design. The database was utilized exclusively for research purposes, and no personal information was accessed. The study was conducted in accordance with the Declaration of Helsinki.

Study population

This study utilized data from the NHIS, including general health screening data and claims data collected from 2012 to 2022. Individuals who had been diagnosed with myocardial infarction (MI) or ischemic stroke prior to the baseline health screening were excluded. From a simple random sample representing 40% of eligible participants in the NHIS database, a total of 4,910,068 adults aged 20 years or older who underwent a health screening between January 1 and December 31, 2012, were included in the study and followed up through December 31, 2022, using linked claims data.

Definition of CVD and comorbidities

Incident CVD was defined as the first occurrence of MI, ischemic stroke, or cardiovascular death. First, MI was defined based on the International Classification of Diseases, 10th Revision (ICD-10) codes I21 or I22 with at least one hospitalization. Ischemic stroke was only applicable to patients who underwent either brain computed tomography or brain magnetic resonance imaging during admission with ICD-10 codes of I63 or I64 [9,10]. Cardiovascular death was defined as any death based on the ICD-10 codes I00–I99 [9,10].

Comorbidities were deemed to be present if participants were ever diagnosed with, or treated for, any of the following conditions using the NHIS database: type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, chronic kidney disease (CKD), or metabolic syndrome. T2DM was indicated by a fasting glucose ≥126 mg/dL or current use of antidiabetic medication with ICD-10 codes E11–E14 [11–14]. Hypertension was diagnosed if systolic blood pressure was ≥140 mmHg or diastolic blood pressure was ≥90 mmHg, or by current use of antihypertensive medications with ICD-10 codes I10–I13, or I15 [11–14]. Dyslipidemia was defined as total cholesterol ≥240 mg/dL or use of cholesterol-lowering medications with ICD-10 code E78 [11–14]. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² or ICD-10 codes V001, V003, or V005 [15]. Metabolic syndrome was diagnosed if three or more of the following components were present: (1) waist circumference (≥90 cm for men and ≥85 cm for women); (2) high blood triglycerides (≥150 mg/dL) or use of a relevant drug; (3) low high-density lipoprotein (HDL) cholesterol (<40 mg/dL for men and <50 mg/dL for women) or use of a relevant drug; (4) high blood pressure (systolic blood pressure  ≥130 mmHg and/or diastolic  blood pressure ≥85 mmHg) or use of antihypertensive medication; and (5) high blood glucose level (≥100 mg/dL) or use of an antidiabetic drug [16].

Clinical and laboratory measurements

Anthropometric, health-related, and biochemical measurements were included in the analysis. Health-related variables included smoking status, alcohol drinking status, and physical activity. Individuals were classified into three groups according to smoking status: never smoker, former smoker, and current smoker. Alcohol drinking status was classified as either non-heavy or heavy drinking, with heavy drinking defined as consuming ≥30 g of alcohol/day [15,16]. Physical activity was defined as performing moderate-intensity physical activity for at least 30 minutes per day on at least 5 days per week, or strenuous-intensity activity for at least 20 minutes per day on at least 3 days per week [15–17]. The eGFR was calculated using the Modification Diet in Renal Disease (MDRD) equation based on baseline serum creatinine [15].

Statistical analysis

Descriptive statistics for the baseline and demographic characteristics of participants were expressed as the mean±standard deviation for continuous variables and as frequencies for categorical variables. Differences in demographic and clinical attributes between study groups were analyzed using the independent t-test for continuous variables and the chi-square test for categorical variables. To estimate incidence rates, Poisson regression models were applied with adjustments for age and sex. Adjusted incidence rates were reported as rates per 100,000 person-years. All statistical analyses were conducted using SAS ver. 9.4 (SAS Institute Inc). P values are two-sided, with a significance level of 0.05.

RESULTS

Study population characteristics

Of the 4,910,068 individuals aged 20 years or older who underwent health screening in 2012, those with missing values in the health screening data (74,201 individuals) and those with preexisting CVD (98,251 individuals) were excluded. A total of 4,737,616 participants were included in the final analysis, and the incidence of CVD was observed through December 31, 2022. The mean follow-up duration was 9.07±1.34 years. The mean age of the total study population was 47.9 years, with men accounting for 54.1% and an average body mass index (BMI) of 23.8 kg/m². Regarding comorbidities, T2DM and hypertension were present in 9.6% and 26.6% of patients, respectively. Dyslipidemia was observed in 19.7% of all subjects, while CKD and metabolic syndrome were co-occurring in 3.6% and 25.9%, respectively (Table 1).

Clinical characteristics according to the occurrence of CVD

Table 2 compares the clinical characteristics of individuals who experienced cardiovascular events (CVD, MI, stroke, and cardiovascular death) with those who did not. The overall incidence of CVD, MI, stroke, and cardiovascular mortality was higher in men, older individuals, and current smokers. Furthermore, these events were more prevalent in individuals with coexisting T2DM, dyslipidemia, CKD, and metabolic syndrome. Patients who developed CVD also exhibited higher fasting blood glucose levels, elevated systolic and diastolic blood pressure, and lower HDL cholesterol levels. Notably, there was no significant difference in the incidence of MI or stroke among subjects who exercised regularly. However, cardiovascular mortality was lower in those who engaged in regular exercise. Additionally, obesity was associated with a higher incidence of CVD, but there was no difference in cardiovascular mortality based on the presence of obesity.

Incidence of CVD according to comorbidities

The combined incidence of CVD (MI, ischemic stroke, and cardiovascular mortality) in the entire adult population was 288.9 per 100,000 person-years. The incidence rate in men was 1.5 times higher than in women (343.1 per 100,000 person-years vs. 235.9 per 100,000 person-years, P<0.001). The incidence rate increased with age, being 4.8 times higher among individuals aged 40 to 64 years and 20.6 times higher in individuals aged 65 years than in those aged 20 to 39 years (Table 3). A similar pattern was observed for the development of MI, stroke, and cardiovascular mortality. The incidence of CVD was 1.6, 1.5, 1.2, 1.4, and 1.4 times higher in patients with T2DM, hypertension, dyslipidemia, CKD, and metabolic syndrome, respectively.

Incidence of MI and stroke

Among the total subjects, the incidence of MI was 154.2 per 100,000 person-years, with men experiencing it 1.4 times more frequently than women. The incidence increased with age, with older adults having a 12.3-fold higher incidence than individuals aged 20 to 39 years. Patients with T2DM, hypertension, dyslipidemia, CKD, and metabolic syndrome showed incidence rates that were 1.6, 1.4, 1.3, 1.4, and 1.4 times higher, respectively (Table 3).

For stroke, the incidence was 134.2 per 100,000 person-years, with men experiencing it 1.4 times more frequently than women. The incidence was 33.2 times higher in older adults than in individuals aged 20 to 39 years. Patients with T2DM, hypertension, dyslipidemia, CKD, and metabolic syndrome had incidence rates that were 1.6, 1.5, 1.2, 1.3, and 1.4 times higher, respectively (Table 3).

Cardiovascular mortality

Among the total subjects, 9.1 per 100,000 person-years died from CVD. The mortality rate was 1.8 times higher in men compared to women and increased with age. All studied comorbidities were associated with significantly higher incidence rates for all cardiovascular outcomes (all P<0.0001 for each comorbidity across all outcomes). Cardiovascular mortality was 1.7, 1.8, 1.1, and 1.4 times higher in those with coexisting T2DM, hypertension, dyslipidemia, and metabolic syndrome, respectively. Notably, the highest increase in cardiovascular death incidence was observed in individuals with CKD compared to those without (17.9 per 100,000 person-years vs. 9.0 per 100,000 person-years) (Table 3).

DISCUSSION

In this study, we provided comprehensive insights into the clinical characteristics and incidence of CVD, including MI, stroke, and cardiovascular death, within the Korean general adult population using the NHIS database. Our findings reinforce well-established risk factors for CVD while also highlighting particular comorbidities in the Korean adult population.

With increased awareness of cardiovascular risk factors and active treatment efforts for CVD and its risk management, the incidence of CVD has been gradually declining. There were decreases in the global age-standardized prevalence rates of ischemic heart disease (IHD; –4.6%; 95% uncertainty interval, –5.7 to –3.6) and IHD deaths (–30.8%; 95% uncertainty interval, –34.8 to ¬–27.2) from 1990 to 2019. In 2019, the global prevalence and death rates of IHD were higher among men across all age groups, while the death rate peaked in the oldest group for both sexes [18]. For ischemic stroke, incidence and mortality rates for both sexes in China, Japan, and Korea decreased overall from 1990 to 2021, consistent with the United States and global patterns, with Korea showing the largest decrease. The average annual percentage declines in the stroke incidence rate and mortality rate were –3.58% and –5.52% in Korea, –1.55% and –3.54% in Japan, and –0.37% and –1.79% in China, respectively. In comparison, the corresponding figures were –1.29% and –1.15%, respectively, in the United States, and –0.81% and –1.60%, respectively, globally [19]. Specifically, the age- and sex-standardized incidence rates of IHD and ischemic stroke also decreased from 2010 to 2019 in individuals with T2DM in Korea. In 2019, among Korean adults aged 30 years or older, the age- and sex-standardized incidence rates for CVD per 1,000 persons were 18.9 for IHD and 5.5 for ischemic stroke. This trend remained consistent regardless of sex in individuals with T2DM (P<0.001) [20]. Data on causes of death from 1983 to 2021 showed that the mortality rate from all circulatory system diseases decreased from 1982 to 2009, but then increased again from 2009 to 2021 in Korea. The mortality rate was 165.9 per 100,000 population in 1983, dropped to 109.2 per 100,000 population in 2009, and then rose to 121.5 per 100,000 population in 2021. Importantly, the mortality rate was consistently higher in men across all age groups [21].

The demographic profile of our cohort showed a mean age of 47.9 years and a slight male predominance (54.1%), with an average BMI of 23.8 kg/m2. Our detailed analysis of clinical characteristics by event status demonstrated that older age, male sex, and current smoking were consistently associated with a higher risk across all CVD outcomes. Similarly, the strong association of T2DM, hypertension, dyslipidemia, CKD, and metabolic syndrome with increased incidence of CVD, MI, stroke, and cardiovascular death is consistent with global epidemiological evidence. The elevated fasting blood glucose, higher systolic and diastolic blood pressure, and lower HDL cholesterol levels observed in event groups further emphasize the critical role of these metabolic and hemodynamic parameters in CVD pathophysiology.

A particularly noteworthy finding pertains to physical activity and obesity in relation to cardiovascular mortality. While regular physical activity was associated with a lower incidence of cardiovascular death, it did not show a significant difference for MI or stroke incidence. This suggests a potential protective effect of regular exercise on fatal cardiovascular events, possibly through mechanisms beyond the prevention of acute MI or stroke, such as improved cardiovascular fitness, reduced arrhythmias, or better management of chronic conditions. This warrants further investigation to elucidate the specific pathways by which regular physical activity confers its benefit on cardiovascular mortality [22,23]. Conversely, although obesity significantly increased the risk of overall CVD, MI, and stroke, its association with cardiovascular death was not statistically significant in the Korean adult population. Further exploration into the causes of cardiovascular death in obese versus nonobese individuals in this cohort would be beneficial [24–26].

The incidence rates presented clearly demonstrate the enormous health burden of CVD in the Korean population. The overall adjusted incidence rate of 288.9 per 100,000 person-years for CVD is a significant public health concern. The 1.5-fold higher incidence of CVD in men compared to women and the dramatic increase in incidence with advancing age—particularly a 20.6-fold higher rate in older adults than in individuals aged <65 years—underscore the need for targeted prevention and management strategies across different demographic groups. The heightened incidence of CVD, MI, stroke, and cardiovascular death in individuals with comorbidities is a critical finding [27–31]. The 1.6-fold higher incidence of CVD in T2DM, 1.5-fold in hypertension, and 1.4-fold in metabolic syndrome clearly demonstrate the cumulative risk conferred by these comorbidities. The most striking increase in cardiovascular death was observed in individuals with CKD, reaching a 2.0-fold higher rate. This highlights CKD as a particularly potent risk enhancer for fatal cardiovascular events, emphasizing the urgency of early detection and rigorous management of CKD in preventing cardiovascular mortality [32,33]. Therefore, while the incidence of CVD has gradually decreased over the past two decades, its prevalence and cardiovascular mortality remain high, particularly among individuals with comorbidities in the Korean adult population. This study highlights the continued importance of managing cardiovascular risk factors and comorbid conditions.

This is a representative dataset evaluating the incidence rates of CVD over the past decade in the entire Korean adult population. Despite the strengths of this study, discrepancies in real diagnosis may exist due to the use of operational definitions for each comorbidity and CVD.

In conclusion, this fact sheet from the Korean Society of Cardio-cerebrovascular Disease Prevention provides robust evidence on the prevalence of cardiovascular risk factors and the incidence of CVD in the Korean adult population. The findings highlight the importance of understanding the impact of lifestyle factors and management of comorbidities for healthcare providers. The significant burden of CVD, particularly among older individuals, men, and those with chronic conditions, necessitates continued public health efforts focusing on primary prevention through lifestyle modifications and aggressive management of established risk factors. Future research should further investigate the clinical implications of lifestyle intervention programs in high-risk subjects to optimize preventive strategies.

ARTICLE INFORMATION

Author contributions

Conceptualization: KH, SSC, SHK; Data curation: KH, JHJ, SSC; Formal analysis: JHJ; Investigation: JHJ, SSC; Methodology: KH, JHJ; Validation: KH; Writing–original draft: SHK; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Seung-Hyun Ko is an associate editor of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

This study was supported by the Korean Society of Cardio-cerebrovascular Disease Prevention.

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Figure & Data

References

Citations

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