INTRODUCTION: In 2021, cardiovascular diseases (CVD) caused around 20.5 million deaths worldwide, making them a major health concern. METHODS: Incidence, prevalence, death, years of life lost (YLL), years lived with disability (YLD), and disability-adjusted life years (DALYs) were the burden measures that were assessed. All measures are reported as both all-age numbers and age-standardized rates (ASR) with 95% uncertainty intervals (UI). Decomposition analysis was conducted on CVD incidence. RESULTS: From 1990 to 2021, all-age CVD prevalence in Iran increased by 182.6% (2.9 to 8.3 million cases), with males consistently showing higher age-standardized prevalence rates (ASPR) than females (11,350 vs. 9,431 per 100,000 in 2021). ASPR remained stable nationally (9,956 to 10,386 per 100,000), peaking in adults ≥80 years. Incident cases rose by 159.6% (0.36 to 0.92 million), driven by population growth (49.5%) and aging (136.2%), while age-standardized incidence rates (ASIR) declined by 28.3% (1,337 to 1,197 per 100,000)
with males (1,336) exhibiting higher rates than females (1,060) in 2021. All age deaths doubled (86,527 to 169,582) during this period, but age-standardized death rates (ASDR) decreased substantially by 42.97% (446 to 255 per 100,000). DALYs increased by 53.7% (2.4 to 3.7 million), though age-standardized DALY rates dropped 45.3% (9,096 to 4,977 per 100,000), dominated by ischemic heart disease (2,731 ASR) and stroke (1,229 ASR). High systolic blood pressure, dietary risks, and LDL cholesterol remained the leading contributors to DALYs nationwide. CONCLUSION: Iran's rising CVD burden demands prioritizing cardiac care infrastructure in underserved provinces like Golestan, enforcing sodium reduction policies aligned with Iran's existing trans-fat regulations, and integrating sex-specific programs such as tobacco control for males and community hypertension screening for women are critical. Multisectoral collaboration, including urban design promoting physical activity and subsidies for whole grains, must address provincial inequities exacerbated by Iran's aging population and dietary risks.