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.

“The views, opinions, and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness, and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions, or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”


AHA18 Reminded Me We Need to Do More for Women

On the surface, it doesn’t really seem that surprising men and women develop heart disease differently or experience different symptoms for the same types of cardiac episodes. However, even though heart disease is the number one killer of both men and women, women have traditionally been omitted from clinical trials and female animals have either not been included in preclinical research studies or the two sexes have been combined1. We just simply weren’t taking half of the population into account at every level of cardiovascular disease (CVD) research for quite some time. I spent my graduate career focused on understanding the baseline differences in the heart between the sexes, and was extremely passionate about this work. Since I spent most of my scientific career working in this field, I wanted to switch it up as a postdoctoral fellow and am currently not researching sex differences. However, when I went to AHA sessions this year, I made it a point to go to any events focused on sex differences and women to get updated on what I’ve been missing this past year. Luckily the “State of the Heart For Women: Top Ten Advances in Gender-Specific Medicine” session provided the perfect summary. After ten great talks focused on a variety of gender specific concerns ranging from heart failure to pregnancy, the take home message was clear: women are still very much at risk, more likely to be misdiagnosed, and are still under-represented in clinical trials. These issues are also worse for women of color.


While this is a widespread issue across disciplines, the cardiovascular field has been particularly biased with regard to including women in clinical trials for drug development, leading to drugs being either not as effective in women or causing different side effects2. The good news is, things are changing. In the early 1990’s, reports from the Food and Drug Agency (FDA) demonstrated that less than 20% of participants in clinical trials were women and recent studies reveal that this number is steadily increasing – even in the cardiovascular field3. Fixing this imbalance is the result of the tireless work from many dedicated researchers over the past several decades. One of the main advocates this field has is Dr. Nanette Wenger, who was the first speaker of this session and actually let me ask her a some questions later during the conference while we were both in the Women in Science and Medicine Lounge. When I asked Dr. Wenger about her strategy for making this issue a priority in our field she explained the key steps to creating change:

  1. Investigate — people can’t ignore what the data is clearly telling them
  2. Educate — teach your peers & patients
  3. Advocate for the change
  4. Legislate — it took a long time, but we’re slowly transforming the strategic plan of the NIH

Dr. Wenger also stressed that since the emphasis in our field now is personalized care, many researchers and physicians are more supportive of including sex in their experiments and/or trials, but we need to move forward by not assuming that women are a homogeneous group. Other factors such as race are also important and must also be considered.

While progress has been made we still have a long way to go on many accounts. While there are more women in clinical trials than in the past, women still only make-up about 34% of the total participants in cardiac clinical trials3. Hopefully, with the passing of the 21st Centuries Cures act and the NIH policy mandating sex be included as an biological variable in basic research studies in 2016, these numbers will progressively increase. At the session before the talks even began, I immediately noticed that all but one of the ten panelists were women (which is awesome, but strange for the cardiac field) and the majority of people in the audience were also women. We will need to continue to advocate for this issue and we need men to join us and take it seriously for real change to be made. Additionally, while I really enjoyed this unique session, the speakers were only given ~10 minutes each to summarize their extraordinarily complex topics, which just wasn’t enough time. It would be great if gender-specific cardiovascular issues were given more time at AHA Scientific Sessions as well as other conferences in the future. This session reminded me just how pressing making CVD treatment equitable for all truly is and thankful for the researchers making it happen.



  1. Blenck CL, Harvey PA, Reckelhoff JF, Leinwand LA. The Importance of Biological Sex and Estrogen in Rodent Models of Cardiovascular Health and Disease. Circ Res. 2016;118(8):1294-312.
  2. Regitz-Zagrosek V. Therapeutic implications of the gender-specific aspects of cardiovascular disease. Nat Rev Drug Discov. 2006;5(5):425-38.
  3. Pilote L, Raparelli V. Participation of Women in Clinical Trials: Not Yet Time to Rest on Our Laurels. J Am Coll Cardiol. 2018;71(18):1970-2.



Highlights of the 1st Annual Sex and Gender Conference at AHA18

Walking into the Palmer House Hotel, the longest continuously operating hotel in the United States, you can’t help but pause in awe at the intricate décor and take in the most photographed ceiling in the world. I make my way to the Honoré Ballroom, named after Bertha Honoré Palmer, the wife of Palmer and an astute businesswoman and well-known Chicago socialite of her time, not knowing what to expect for the 1st annual Sex and Gender Influence on Cardiovascular Disease (CVD) conference.

Annabelle Volgman, medical director of the Rush Heart Center for Women, kicks off the evening by thanking the speakers and planning members, and encouraging photography and social media sharing. The many photos of the evening include Bertha Honoré’s portrait adjacent to the colorful and modern logo that, I think, will become a recognized image at future AHA Scientific Session meetings.

Dr. Annabelle Volgman welcomes attendees to the 1st Annual Sex and Gender Influences on Cardiovascular Disease at the Palmer Hotel in Chicago, IL (November 11, 2018).


Dr. Nanette Wenger of the Emory Women’s Heart Center starts the conversation with her presentation titled “Why is Mortality from Cardiovascular Disease Rising in Men and Women?” She flashes a graph of CVD mortality on the screen, highlighting the steep decline in the past decades, but the leveling off and reversal in recent years, particularly in women under the age of 55 years. The parallel rise in obesity and diabetes, as well as “non-traditional” CVD risk factors such as depression and perceived stress disproportionally affect women, she explains, and may be responsible for this reversal in CVD death rates. Summarizing the recent paper, “Defining the New Normal in Cardiovascular Risk Factors” by Dr. Donald Lloyd-Jones and Dr. Philip Greenland she points to a combination of health behaviors and ideal levels of total cholesterol, blood pressure, and fasting blood glucose, as key factors in achieving cardiovascular health.

“Behavior change,” she says, “is the ‘Holy Grail’ of heart health” and as “health professionals take back the role [of health educator] and address lifestyle behaviors” we will see favorable trends in biomarker targets we’re so interested in.

Later during the Q+A panel, when asked about the best way to approach behavior change with patients, she advises to first, “Give information – if your patient does not have the information, they can’t make a change. Then, let them start with what they would like to start with. Don’t give them 8-10 [health behaviors] to change – they will tune you out.” Dr. Gina Lundberg, co-director of the Emory Women’s Heart Center, chimes in that the clinician’s “approach to weight loss is similar to smoking cessation. Identify the obstacles in the patient’s way – money, time, desire – and often just identifying those hurdles will lead to improvement.”

Dr. Laxmi Mehta, director of the Women’s Cardiovascular Health Program at the Ohio State University Wexner Medical Center, adds that she includes an emotional appeal – “Where is the patient going and what do they want?” Seeing a child’s wedding or playing with their grandkids, developing rapport with patients and fitting your recommendations to their goals can start the health behavior change process, even in a 5 minute clinician-patient discussion.