Alcoholic cardiomyopathy (ACM) results from chronic alcohol misuse and primarily affects the working-age population (15-64 years). The global age-standardized rates (ASRs) of ACM disease burden declined slightly from 1990 to 2021, but the absolute cases increased, especially in high‒medium sociodemographic index (SDI) regions such as Eastern Europe. The aim of this study was to inform strategies to combat this preventable yet escalating health issue.We calculated estimated annual percentage changes (EAPCs) to quantify the dynamics of prevalence, deaths, and disability-adjusted life years (DALYs) for ACM. Decomposition analysis quantifies the contributor of disease burden in ACM. Additionally, we employed a health inequality analysis with two core indicators, the slope index (SI) and the concentration index (CIN), to assess national differences in the burden of ACM in relation to the SDI. Frontier analysis was used to identify preventable burdens with respect to optimized alcohol policies, particularly in high-middle SDI countries. Finally, we applied a Bayesian age‒cohort (BAPC) model to project the ACM burden to 2035.This study revealed that the ASRs of prevalence, deaths, and DALYs decreased slightly from 1990 to 2021, whereas absolute cases of ACM continued to increase globally. Global income-based health disparities in ACM have intensified over the past 32 years, with high SDI populations disproportionately favoured. Population growth was the main driver of the increased ACM burden. The global burden of ACM is expected to increase in the future according to the BAPC model.The global burden of ACM continues to rise, primarily due to population ageing and insufficient prevention policies. This burden disproportionately impacts working-age populations, who face heightened vulnerability due to alcohol accessibility, premature mortality, and reduced workforce productivity. Moreover, economic growth paradoxically coincides with increased alcohol-related harm in regions with high-middle socioeconomic development-the alcohol control paradox. Projections highlight an urgent need for tailored alcohol control strategies, including stricter regulation and early cardiac screening in high-risk groups, to mitigate workforce productivity loss and align public health priorities with sustainable development goals.© 2025. The Author(s).