Representation of women in cardiovascular disease management: a systematic analysis of ESC guidelines

Sex differences play a critical role in the presentation, progression and treatment outcomes of cardiac diseases. However, historical male predominance in clinical studies has led to disparities in evidence supporting care for both sexes. Clinical guidelines are essential for cardiovascular care, shaping practice and influencing patient outcomes. In this study, we reviewed 34 European Society of Cardiology (ESC) guidelines between 2002 and 2024 to evaluate the representation of women and the inclusion of female-specific recommendations.

We compiled 136 gender-related keywords, validated by six clinicians, and quantified their occurrence across guidelines. While our primary analysis focused on female-specific keywords, we also identified male-specific terms as a comparison point to help quantitatively interpret the representation of female-specific terminology in the guidelines. Each guideline underwent independent review by two auditors who used structured questions to assess its sensitivity to female-specific differences in disease presentation, diagnosis, management and treatment.

The most frequent terms were 'pregnancy', 'women' and 'sex', with 1768 (17.9%), 1573 (15.9%) and 676 (6.8%) overall repetitions, respectively, contrasted against 'cardiac' (6932 occurrences) as a baseline. Results showed inconsistency in addressing female-specific factors and health considerations in ESC guidelines. We were able to assess the relative frequency of female-specific language and highlight in contrast areas where female representation in cardiovascular guidelines may be insufficient. Most guidelines (24/34) mentioned pregnancy and provided related recommendations, with one of the guidelines entirely dedicated to cardiovascular disease (CVD) in pregnancy (2018) and a new one planned for 2025. Only 10/30 guidelines acknowledged menopause as a CVD risk factor and offered recommendations for clinical practice.

These findings highlight the need for systematic integration of female-specific considerations across all guidelines. In the wider context, there is also a need for improved representation of women in clinical trials and for making the available evidence on which the guidelines are based less biased toward men.