To quantify trends in stroke, ischaemic heart disease (IHD), and hypertensive heart disease (HHD) in Sierra Leone from 1990 to 2023 using Global Burden of Disease (GBD) Study 2023 estimates. We analyzed GBD 2023 estimates for deaths, disability-adjusted life years (DALYs), incidence, and prevalence. We decomposed changes in absolute burden into population growth, population ageing, and epidemiological change and summarized risk-factor population attributable fractions (PAFs). From 1990 to 2023, DALYs increased from 81,263 to 131,911 for stroke, from 40,780 to 79,445 for IHD, and from 10,163 to 23,817 for HHD. Age-standardised DALY rates declined for stroke (3667 to 3355 per 100,000; -8.5%) but increased for IHD (1885 to 2019; +7.1%) and HHD (467 to 586; +25.5%). Population growth accounted for most of the rise in absolute deaths and DALYs across causes, while epidemiological change differed by cause. Notably, the steepest proportional increases in DALYs occurred among adults aged 35-44 years, indicating disproportionate burden growth during economically productive ages. In 2023, high systolic blood pressure was the leading risk factor for all three causes; for IHD, air pollution (PAF 41.7%) and lead exposure (32.1%) were also prominent. This 100% PAF for high systolic blood pressure for HHD reflects the GBD definitional framework. Sierra Leone has experienced rising absolute cardiovascular burden since 1990, with divergent age-standardized trends across causes. Consideration for prevention include blood pressure control and environmental risk reduction, though specific policy priorities should be guided by local feasibility assessments and interventional evidence.