Gender Disparity in the Guideline Authorship, More Work Needs to Be Done on the International Level

Women have been widely underrepresented in cardiology over the past decades. Lately, over the last decade, the American College of Cardiology/American Heart Association (ACC/AHA) has made active efforts to bridge this gap. Other international societies such as the European Society of Cardiology (ESC) and the Canadian Cardiovascular Society (CCS) have also made similar efforts. However, the fruition of these efforts remains questionable. Although there is closure parity in the number of men and women entering medical school, the percentage of women continues to decrease as they advance in their career from medical school to residency and further to fellowship. This phenomenon has been called a “leaky pipeline,” which continues to drop down further going into academics and progressing to leadership.1

As per recent original research published in the Journal of American Heart Association, there is persistent disparity in including women in the guideline authorships from the ACC/AHA, ESC, and CCS guidelines from 2006-2020.2 The authors extracted all published guidelines from 2006-2020, reporting 80 ACC/AHA (1288 authors, 28% women), 64 CCS (988 authors, 26% women), 59 ESC (1157 authors, 16% women) guidelines suggesting vast underrepresentation of women in the leadership. There is a positive trend towards inclusion of women in the ACC/AHA guidelines, from11 (12.6%) in 2006 to 63 (42.6%) in 2020 (average annual percentage change, 6.6% [2.3% to 11.1%];P=0.005).2 There was a similar increase in the inclusion of women in the ESC guidelines as well, from 1 (7.1%) in 2006 to 23 (25.8%) in 2020 (average annual percentage change, 6.6% [0.2% to 13.5%]; P=0.04). Interestingly, the inclusion of women in CCS guidelines remained similar over the years.

In recent years, there has been a comparatively higher inclusion of women in ACC/AHA than CCS and ESC. This could be reflective of earlier efforts initiated by ACC/AHA back in 1995 by setting up nationwide and statewide women in cardiology chapters to promote women in cardiology. The study reported a higher inclusion of women in the guideline writing group when a woman was a chair or at least one of the chairs was women in the ACC(48% versus 30% versus 21%; P<0.0001) and ESC (43% versus 34% versus 14%; P<0.0001) guidelines; however, a similar trend was not seen in the CCS guidelines. These results are intriguing, as guideline writing committees are chosen independently by the task force group without direct input from the chairs. These results suggest inherent bias in the selection of writing group members.2

The authors also report women authors’ inclusion in general cardiology and subspecialties, reporting a higher inclusion of women in pediatric cardiology and heart failure followed by general cardiology and lowest in interventional and electrophysiology guidelines. The lower inclusion of women in the intervention and electrophysiology guidelines is likely secondary to fewer women in these fields; this has been likely attributed to the procedure-oriented areas and women shying away from these fields due to potential radiation exposure. Currently, professional societies like Women as One SCAI have put special efforts to promote women in the procedure-oriented fields and decrease overall radiation exposure.3-6

Another interesting aspect of this study was the repetition of the unique authors (the same authors being included in multiple guidelines) revealed 31.9% of women authors were repeat authors, which was similar to 32.9% of men authors. However, the highest frequency of inclusion of repeated men authors was higher than women. The authors propose limiting the number of times an author can be included on guidelines as a potential way to encourage more women in cardiology in the leadership.

It is important to achieve parity in the guideline authorship group as this group should reflect the population we serve. Prior studies have also supported that having a diverse physician group or patient treated by physicians of similar racial and ethnic backgrounds has better clinical outcomes. Thus, concerted efforts to plug the leaky pipeline at every step can help achieve gender parity in cardiology and promote leadership among women in cardiology.1

Prominent researcher and senior author Dr. Martha Gulati says: “This work was led by fellow-in-training Dr. Devesh Rai. He was particularly interested in the need for the inclusion of women in cardiology. I was honored to serve as the senior author and mentor of Dr. Rai and am grateful that the upcoming generation of cardiologists, regardless of whether male or female, are interested in seeing a change in our cardiology community in terms of diversity, equity, and inclusion.

Our work demonstrated that there is a significant disparity in the inclusion of women on all national guideline committees within AHA/ACC, ESC, and the CCS. Additionally, women are less likely to serve as a chair of cardiology guidelines. Further advocacy is required to promote equity, diversity, and inclusion in our cardiology guidelines globally.”


  1. Arnett DK. Plugging the Leaking Pipeline. Circulation: Cardiovascular Quality and Outcomes. 2015;8:S63-S64.
  2. Rai D, Kumar A, Waheed SH, Pandey R, Guerriero M, Kapoor A, Tahir MW, Zahid S, Hajra A, Balmer‐Swain M, Castelletti S, Maas AHEM, Grapsa J, Mulvagh S, Zieroth S, Kalra A, Michos ED and Gulati M. Gender Differences in International Cardiology Guideline Authorship: A Comparison of the US, Canadian, and European Cardiology Guidelines From 2006 to 2020. Journal of the American Heart Association. 2022;11:e024249.
  3. Cardiology ACo. Welcome to the Women in Cardiology (WIC) Member Section!
  4. Cardiology ESo. EAPCI Women Committee.
  5. Cardiology ESo. Women in Electrophysiology.
  6. Interventions SoCA. Women in Innovations.

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