Recognising sex and gender differences in cardiovascular care is vital to CHD prevention, diagnosis and treatment. The British Cardiovascular Society’s Women in Cardiology Committee explain
Coronary heart disease (CHD) causes twice the fatalities in UK women as breast cancer (1) and yet despite this, it is under-recognised and under-treated. The persistent misconception of low risk in women leads to delays in seeking care and receiving treatment. (2) The joint British Cardiovascular Societies’ recent consensus statement in Heart aims to raise awareness of the scale of this problem and proposes strategies to overcome the barriers faced by women. (3)
Sex and gender differences in CHD are due to several factors. Primary care often focuses on traditional risk factors in men, commencing primary preventative regimes earlier in this cohort. (3) Women are often older with more comorbidities and different symptomatology, which affects CHD identification and subsequent pharmacological or interventional management. Socioeconomic and psychosocial factors also make women more reluctant to engage in self-care or rehabilitation, leading to worse outcomes.(2)
Heart disease in women vs men: Biological differences
Key biological differences between men and women affect disease presentation, pathophysiology, and prognosis. (4,5) Women are more susceptible to conditions including coronary microvascular disease, coronary artery spasm, spontaneous coronary artery dissection, takotsubo cardiomyopathy, endothelial dysfunction, heart failure with preserved ejection fraction and autoimmune conditions. (5,7) They also show differing responses to pharmaceuticals, which influences treatment plans and outcomes. Women present later with cardiovascular disease due to the protective effects of oestrogen, which decline with the menopause, along with progesterone and androgen levels. This hormonal decline detrimentally affects protective mechanisms, leading to adverse increased LDL-cholesterol, (8) higher risk of hypertension, (9) type 2 diabetes mellitus (10) and more metabolic syndrome occurrences/stigmata (11) including non-alcoholic fatty liver disease. (12) These changes increase the incidence of CHD in post-menopausal women. Understanding these factors is crucial for early cardiovascular risk assessment and intervention both during, prior and after the menopause. Moreover, exploring hormone replacement therapy’s role in mitigating these risks and improving cardiovascular health is imperative. However, evidence for managing menopause symptoms in women with cardiovascular disease remains limited. (9) Additionally, awareness of unique risk factors like gestational diabetes and pre-eclampsia is vital due to possible long-term cardiovascular effects.
Gender disparity in cardiovascular research
Women are underrepresented in cardiovascular research, which contributes to worse outcomes. Randomised controlled trials have historically under- recruited women, (6,13) in part due to underdiagnosis (14) and undertreatment, (5) resulting in fewer opportunities to consider entering these women into trials. Trial criteria often exclude women of childbearing age and/or pregnant patients, or discriminate them via indirect measures such as mandating a minimum drug dose or a maximum age. There are, therefore, many cardiovascular medications that remain inadequately tested in women, potentially impacting treatment effectiveness.
Cardiology also faces a significant gender disparity within the workforce, with inadequate representation of women as clinicians, leaders and researchers. Only 28% of trainees and 13% of consultants are female, despite women forming over half of all medical training posts. (15,16) This deficit is even more pronounced in academia, where women account for just 18.8% of first authors and 11.9% of last authors. (17) Barriers include a lack of role models, family commitments, pay inequality, and inherent sexism. (18,19) Addressing the gender imbalance in cardiology training could expand the representation of women in cardiovascular research and clinical practice. Trials led by female investigators have a higher enrolment of women, enhancing research outcomes and inclusivity. (20)
Research gaps underscore the need to study sex and gender-specific impacts on cardiovascular health in women. Trials must include more women to allow adequate power for sex and gender-specific sub- analyses. A positive effect of increasing the number of women in cardiology could catalyse a self-perpetuating cycle of more women designing, leading, and subsequently participating in clinical trials. The British Cardiovascular Society’s Women in Cardiology Committee promotes women in training through education and mentorship. Raising awareness of heart disease in women is crucial, as this remains their biggest killer.
Authors
- Bethan Maidment1, Sarah Birkhoelzer2, Holly Morgan3, Josephine Mansell4, Joanna Lim5 and Gill Louise Buchanan6 on behalf of the Women in Cardiology Committee, British Cardiovascular Society*
- *BM, SB, HM and JM contributed equally to this manuscript
- Lancaster Medical School, Lancaster University, UK
- Oxford Centre for Magnetic Resonance, Oxford University, UK
- King’s College, London, UK
- National Amyloidosis Centre, Royal Free Hospital, London, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- North Cumbria Integrated Care NHS Foundation Trust, Cumberland Infirmary, Carlisle, UK
References
- Women and heart disease: the gender gap – BHF https://www.bhf.org.uk/informationsupport/support/women-with-a-heart-condition/women-and-heart-disease#:~:text=Women%2520are%2520twice%2520as%2520likely,seen%2520as%2520a%2520woman%C3%A2%C2%80%C2%99s%2520problem
- Thakkar A, Agarwala A, Michos ED. Secondary Prevention of Cardiovascular Disease in Women: Closing the Gap. Eur Cardiol. 2021 Nov 8:16:e41
- Tayal U, Pomeper G, Wilkinson I et al. Advancing the access to cardiovascular diagnosis and treatment among women with cardiovascular disease: a joint British Cardiovascular Societies’ consensus document. Heart 2024;110:e4
- Lansky AJ, Ng VG, Maehara A, et al. Gender and the extent of coronary atherosclerosis, plaque composition, and clinical outcomes in acute coronary syndromes. JACC Cardiovasc Imaging. Mar 2012;5(3 Suppl):S62-72. doi:10.1016/j.jcmg.2012.02.003
- Haider A, Bengs S, Luu J, et al. Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. Eur Heart J. Apr 2020;41(13):1328-1336. doi:10.1093/eurheartj/ehz898
- Morgan H, Sinha A, Mcentegart M, Hardman SM, Perera D. Evaluation of the causes of sex disparity in heart failure trials. Heart. Mar 31 2022;doi:10.1136/ heartjnl-2021-320696
- Sullivan K, Doumouras BS, Santema BT, et al. Sex-Specific Differences in Heart Failure: Pathophysiology, Risk Factors, Management, and Outcomes. Can J Cardiol. 04 2021;37(4):560-571. doi:10.1016/j.cjca.2020.12.025
- Palmisano BT, Zhu L, Stafford JM. Role of Estrogens in the Regulation of Liver Lipid Metabolism. Adv Exp Med Biol. 2017;1043:227-56.
- Miller VM, Duckles SP. Vascular actions of estrogens: functional implications. Pharmacol Rev. 2008;60(2):210-41
- Yazdkhasti M, Jafarabady K, Shafiee A, Omran SP, Mahmoodi Z, Esmaeilzadeh S, et al. The association between age of menopause and type 2 diabetes: a systematic review and meta-analysis. Nutr Metab (Lond). 2024;21(1):87.
- Carr MC. The Emergence of the Metabolic Syndrome with Menopause. The Journal of Clinical Endocrinology & Metabolism. 2003;88(6):2404-11.
- Yang C, Chen S, Feng B, Lu Y, Wang Y, Liao W, et al. Association between menopause, body composition, and nonalcoholic fatty liver disease:
A prospective cohort in northern China. Maturitas. 2025;192. - Jin X, Chandramouli C, Allocco B, Gong E, Lam CSP, Yan LL. Women’s Participation in Cardiovascular Clinical Trials From 2010 to 2017. Circulation. 02 2020;141(7):540-548. doi:10.1161/CIRCULATIONAHA.119.043594
- Nguyen JT, Berger AK, Duval S, Luepker RV. Gender disparity in cardiac procedures and medication use for acute myocardial infarction. Am Heart J. May 2008;155(5):862-8. doi:10.1016/j.ahj.2007.11.036
- Birkhoelzer, S. M., Kadavath, S. & Cader, A. Global WIC-Early Careers: Building an International Multidisciplinary Network of Women in Cardiology. JACC Case Rep 2, 2033–2036 (2020).
- Sinclair, H. C. et al. Women in Cardiology: The British Junior Cardiologists’ Association identifies challenges. Eur Heart J 40, 227–231 (2019).
- Goel, R. et al. Geographic Mapping of Gender Disparities in Authorship of Cardiovascular Literature. J Am Coll Cardiol 83, 2458–2468 (2024).
- Jaijee, S. K., Kamau-Mitchell, C., Mikhail, G. W. & Hendry, C. Sexism experienced by consultant cardiologists in the United Kingdom. Heart 107, 895–901 (2021).
- Buchanan, G. L. et al. Overcoming professional barriers encountered by women in interventional cardiology: an EAPCI statement. Eur Heart J 44, 1301–1312 (2023).
- Chhaya, V. Y. et al. Gender Bias in Clinical Trial Enrollment: Female Authorship Matters. Ann Vasc Surg 95, 233–243 (2023).