From the margins to the center: Transforming cardiovascular care for women

Abstract

Cardiovascular disease (CVD) remains the leading cause of death among women worldwide, with significant disparities in prevalence, outcomes, and care. Despite these alarming statistics, research on women’s heart health remains underfunded and poorly prioritized, due in part to the historic exclusion of women from clinical trials and biomedical research. This editorial will highlight the scope of CVD in women, explore sex- and gender-specific risk factors such as gestational diabetes, early menopause, and psychosocial stress, and underscore barriers to quality care including implicit bias and structural inequities. It also calls for increased representation of women in clinical trials and medical fields. Policy and funding shifts are urgently needed to encourage sex-specific research and equitable healthcare delivery. This editorial concludes with a call to action for inclusive, interdisciplinary research approaches, that centers women and their unique biological realities. Advancing gender-responsive cardiovascular care will require not only scientific innovation but also institutional accountability and societal commitment to health equity.

Introduction: women’s heart health

Cardiovascular disease (CVD), which includes conditions affecting the heart and blood vessels, remains a global public health crisis. According to the Cleveland Clinic, ¹ CVD is responsible for one in three deaths worldwide each year among adult populations. The American Heart Association, ² reports that when accounting for race and ethnicity, Black women have a significantly higher prevalence of CVD at 59%, compared to their White, Latina, and Asian counterparts, whose rates range from 37% to 45%. These disparities serve as an example of how CVD poses not only a major public health challenge but also a serious threat to health equity.

With these inequities, it is vital to prioritize research on women’s experiences with CVD. This area remains underexplored partly due to the underrepresentation of women in Science, Technology, Engineering, and Mathematics (STEM) fields and the fact that only 27%—36% of clinical trial participants are women. ³ This gap signals the need for mentoring female scholars, particularly those with lived experience, to lead research on the biopsychosocial determinants, barriers to care, and treatment strategies for CVD in women. This editorial will outline the burden of CVD in women, explore current gaps in understanding the condition, and call for greater inclusivity in research, especially in clinical trials. It advocates for expanding opportunities for women in STEM and ensuring their voices inform behavioral and biomedical studies.

Understanding the scope: prevalence and impact of CVD in women

CVD accounts for approximately 35% of all female deaths globally, making it the leading cause of mortality among women. ⁴ In 2019, age-standardized cardiovascular mortality among women reached 204 deaths per 100,000, primarily due to ischemic heart disease (95/100,000) and stroke (74/100,000). Regional disparities were stark, with Central Asia experiencing the highest mortality rates (486 per 100,000) compared to high-income Asia-Pacific (62 per 100,000). ⁴ For context, according to the WHO, 9 million people died of CVD in 2021 and Alzheimer’s disease (with 68% of diagnoses going to women) accounted for a much smaller 2 million deaths. ⁵ Another measure of disease burden for CVD is disability adjusted life years (DALYs), which is the sum of years of life lost plus years lived with disability. When compared to all diseases, the Global Burden of Cardiovascular Diseases and Risks 2023 Collaborators found that CVD is the leading cause of DALYs globally, accounting for 19.9% of all DALYs in 2023, up from 11% in 1990. ⁶

Encouragingly, between 1990 and 2019, global age-standardized CVD mortality in women declined by 1.48% annually, with the steepest declines in high-income Asia-Pacific (−3.77%), Australasia (−2.97%), and Western Europe (−2.69%). ⁴ However, increases in Central Asia and Oceania highlight persistent inequities. Moreover, despite declining rates, the absolute burden of CVD continues to rise due to population aging.^7,8

Predictors and risk factors: what makes women vulnerable?

While women share common CVD risk factors with men, such as hypertension, diabetes, smoking, obesity, and inactivity, these often affect women differently or more severely. ⁹ For instance, hypertension is more prevalent and less well-controlled in women over 60, with African American women experiencing earlier onset and greater severity. ¹⁰ For context, Lewis et al. ¹¹ study demonstrated that chronic exposure to everyday discrimination is associated with increased coronary artery calcification among African American women, highlighting a critical psychosocial determinant of cardiovascular risk. This points to a need for research on longitudinal pathways, mechanisms involving stress biology, and interventions that mitigate discrimination-related cardiovascular harm. Both aging and the onset of menopause are key concerns for women. Samargandy et al. ¹² study of blood pressure (BP) trajectories revealed that about one-third of women experience a marked acceleration in systolic BP and pulse pressure within 1 year after menopause. Additionally, Ji et al. ¹³ revealed that CVD risk typically begins to rise at lower systolic BP thresholds in women compared to men. And Ji et al. ¹⁴ demonstrated that BP in women rises more steeply than in men and starts as early as the third decade of life pointing to a need for future investigations exploring the (1) biological and environmental drivers of accelerated BP in women and (2) development of sex-specific prevention and intervention strategies for hypertension in early stages of life.

Sex-specific conditions further elevate women’s risk. For instance, gestational diabetes increases the likelihood of type 2 diabetes and CVD later in life. ¹⁵ Early menopause reduces estrogen’s protective cardiovascular effect, increasing the risk of atherosclerosis. ¹⁶ Conditions like polycystic ovary syndrome and autoimmune diseases such as lupus and rheumatoid arthritis also heighten risk through metabolic and inflammatory pathways. Besides, psychosocial factors, particularly stress and depression, disproportionately impact women’s cardiovascular health. ¹⁷

Barriers to quality care: gaps in diagnosis and treatment

Women face several unique barriers to high-quality CVD care. First, the historical exclusion of women from clinical trials means that much of today’s evidence base reflects male physiology and symptomology. ¹⁸ Consequently, symptoms more common in women, such as fatigue or nausea, may be overlooked or misattributed. ¹⁹ Although it is challenging to quantify this disparity, the British Heart Foundation reported that female patients are 50% more likely than their male counterparts to be misdiagnosed when having a heart attack. ²⁰ Second, gender bias in healthcare leads to women’s symptoms being minimized or dismissed, particularly among women of color. ²¹ This bias can result in underdiagnosis, delayed treatment, and poorer outcomes. ²² Al Hamid et al. ²³ identified pervasive gender bias in CVD diagnosis, prevention, and treatment, underscoring how inequities contribute to poorer outcomes in women. Future work should focus on developing gender-sensitive clinical guidelines, improving representation of women in CVD trials, and designing interventions that reduce diagnostic and therapeutic disparities. Third, social determinants of health, such as poverty, geographic isolation, education, and access to care, disproportionately affect women, especially those from marginalized communities. ²⁴ Women living in rural or low-resource settings often face greater provider mistrust, limited healthcare access, and structural discrimination. ²⁵

Policy and funding: closing the research and care divide

Despite being the leading cause of death in women, heart disease remains under-recognized and underfunded in both research and practice. ²⁶ A longstanding male-centric approach to studying CVD has led to gender disparities in symptom recognition, diagnosis accuracy, and treatment outcomes. ²⁷ Although awareness of sex-based differences is improving, policies and funding mechanisms often fail to reflect this knowledge. The Lancet women and CVD commission is an international, interprofessional group of health experts working to reduce the burden of CVD on women across the globe. ²⁶ Together, they make policy recommendations informed by an international biopsychosocial strategy. Future scholars and policy makers should use their ecological model to research this public health crisis and create policies to promote health equity. Increased advocacy is needed to promote dissemination through diverse channels, including policy briefs, social media, and community outreach, to raise awareness beyond academic and medical circles.

To close the gap, funding must support research into sex- and gender-specific differences in CVD presentation, risks, and responses to treatment. This includes integrating evidence into clinical guidelines, training healthcare workers, and tailoring public health messaging to women across life stages, including pregnancy and menopause. ²⁸ Equitable care also demands dismantling systemic and cultural barriers, particularly for marginalized groups. ²⁹

Future directions: a call to action for inclusive research

Future research must be intentionally inclusive and interdisciplinary. ³⁰ Women remain underrepresented in clinical trials, limiting our understanding of sex-specific CVD mechanisms and responses to treatment. ³¹ Research design should ensure adequate female representation and include sex- and gender-specific variables, such as reproductive history and social context. ³² Innovative screening approaches, such as leveraging routine mammograms for CVD risk prediction, may improve early detection in women. Additionally, more work is needed on the CVD-related benefits of hormone replacement therapy (HRT) because estrogen levels decrease with menopause, thus depleting women of a CVD risk-reducing hormone. Hodis et al. ³³ showed that when compared to other medications and therapies for CVD, HRT is shown to have minimal overall health risk, affordable prices, and a higher benefit score in a risk/benefit analysis. They recommended for women to receive HRT before 60 and/or within 10 years of experiencing menopause. Nudy et al. ³⁴ corroborated these findings, using a meta-regression analysis of existing literature on CVD and HRT. Their results showed that earlier use of HRT led to greater benefits in terms of cardio event prevention. Their results also point to a need for empirical studies that examine this relationship directly and using medical records or echo or electro cardiograms, not self-reported cardio events. Interdisciplinary efforts spanning basic science, clinical research, public health, and healthcare systems are crucial to addressing the multifaceted nature of women’s cardiovascular health. ²¹ Evidence shows that the diagnosis and experiences of CVD vary by sex. Temkin et al. ³⁵ argue for gender-specific research on CVD and for the National Institutes of Health to prioritize women’s health as an area in need of government grant funding. This means dismantling the narrative that gender-specific research is “exclusionary” or “discriminative” and conceptualizing it as vital and lifesaving. Harmonized data collection across regions will facilitate a better understanding of disease patterns and inform tailored prevention programs. Additionally, raising awareness among women and healthcare providers about CVD symptoms and risk factors is vital for timely diagnosis and management. ²²

Conclusion

Women’s cardiovascular health is both a global health priority and a key equity issue. Although age-standardized mortality rates have declined, disparities persist due to exclusionary research practices and inequities in care delivery. Addressing these gaps requires integrating women’s health needs into every stage of the health research and delivery pipeline, from trial design to public messaging. Increased funding, inclusion of women in clinical trials, and attention to sex-specific biology and social determinants are critical for progress. By fostering interdisciplinary collaboration, empowering female STEM researchers, and implementing gender-responsive policies, we can close the heart health gap. The future of cardiovascular care must be inclusive, data-driven, and attuned to women’s needs across the life course. Only then can we truly reduce the global burden of CVD among women.