Overview: the persistent gender gap in heart disease care
Despite decades of awareness and targeted initiatives, women with heart disease continue to face under-recognition, under-diagnosis and under-treatment. Since Bernadine Healy’s 1991 critique of sex bias in coronary disease management, efforts have aimed at leveling care for women. Yet, 34 years later, sex-based differences in management and outcomes remain evident in Australia and globally. Understanding why these gaps persist is essential for clinicians, policy-makers and patients themselves.
New evidence from New South Wales: what Kazi and colleagues found
The recent study by Kazi and colleagues analyzed adults presenting with a first episode STEMI to New South Wales hospitals from 2011–2020. They looked at seven-day revascularisation rates and 12-month outcomes, focusing on whether sex differences in treatment and prognosis changed over time. The key findings echo prior research: female STEMI patients were older at presentation, had more comorbidity, and were more likely to live in socio-economically disadvantaged areas. They were also less likely to receive timely angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). As a result, 12-month adverse events and mortality were higher among women compared with men.
Encouragingly, while angiography and PCI rates rose for both sexes from 2011 to 2020, the increases were more rapid for women. Likewise, declines in cardiovascular and all-cause mortality over the decade were somewhat faster in women, indicating a gradual narrowing of the treatment gap. However, the mortality gap did not disappear, underscoring the need for targeted action to accelerate progress.
Why do these gaps persist?
Several factors likely contribute to the observed differences. The study’s retrospective design limits causal conclusions, but the authors highlight plausible contributors: higher mean age and greater burden of comorbidity among women; a higher prevalence of myocardial infarction with non-obstructed arteries; and spontaneous coronary artery dissection, which can complicate diagnosis and management. Socioeconomic disadvantage can also impact access to timely care, adherence to guideline-directed therapies, and overall health outcomes. These intersecting biological and social determinants demand a comprehensive response.
What is driving improvement—and what remains to be done
The narrowing gap over ten years is a positive signal. Possible drivers include: greater awareness of sex-specific disease presentations, more inclusive risk assessment, and a broader acceptance that women’s heart disease can present differently than the male norm. Importantly, the improvements occurred without explicit sex-based intervention programs in some settings, suggesting that universal enhancements in care can benefit women as well. Nonetheless, the study also shows that progress is uneven and slow: a ~6 percentage point difference in 12-month mortality persists, underscoring the urgency of more proactive strategies.
Strategies to close the gender gap more rapidly
- Enhance early recognition of female-specific presentations of heart disease through clinician education and public awareness campaigns.
- Promote equitable access to diagnostic and therapeutic procedures, including timely angiography and revascularisation, regardless of age or socioeconomic status.
- Integrate sex-specific data into clinical guidelines and quality metrics to monitor disparities and drive accountability.
- Support research into female-specific pathophysiology, including trends like spontaneous coronary artery dissection, to inform tailored treatment pathways.
- Engage patients, advocacy groups, and policymakers in co-designing interventions that reduce barriers to care for women.
Closing thoughts for clinicians and policymakers
The slow but steady narrowing of the gender gap in STEMI care is heartening, but it is not enough. The goal must be parity in diagnosis, treatment and outcomes for women with heart disease. Fully understanding why differences persist is the first step toward principled action by clinicians, health systems and society. By prioritising equitable care today, we can shorten the time to equality and improve survival for women living with heart disease.
