Cardiovascular imaging in women: from diagnostic bias to inclusive cardiovascular science

Cardiovascular disease remains the leading cause of mortality among women worldwide.1 Despite this fact, sex-specific differences in pathophysiology, clinical presentation, and disease progression remain insufficiently recognized in clinical practice.2 Historically, diagnostic frameworks, research cohorts, and imaging reference values have largely been derived from male populations, contributing to persistent gaps in the identification and management of cardiovascular disease in women.3 Cardiovascular imaging plays a central role in addressing these gaps. Advances in multimodality imaging have improved the ability to detect structural, functional, and microvascular abnormalities that may manifest differently in women versus men. Conditions such as myocardial infarction with non-obstructive coronary arteries, coronary microvascular dysfunction, stress-induced cardiomyopathy, and pregnancy-related cardiovascular disease illustrate the importance of imaging approaches capable of recognizing sex-specific phenotypes and improving diagnostic accuracy.4–7 Incorporating sex-aware imaging strategies into clinical practice is an important step towards more personalized cardiovascular care. However, current imaging parameters and reference values remain largely derived from non–sex-specific standardization,8 limiting accurate phenotypic characterization in women. Sex differences in cardiovascular disease are not limited to adulthood but originate early in life. Evidence suggests that differences in cardiovascular development, congenital heart disease prevalence, and early disease expression are already evident in paediatric populations. Sex-related variations have been described in the incidence and outcomes of congenital heart diseases, arrhythmias, and cardiomyopathies, as well as in the transition from paediatric to adult cardiovascular care. These observations suggest that sex-specific cardiovascular phenotypes evolve across the lifespan, beginning from foetal and early postnatal development.9–11 Despite this, paediatric cardiovascular imaging and diagnostic frameworks rarely incorporate sex-specific reference values or interpretation strategies. Extending a sex-aware imaging approach to paediatric cardiology may represent a crucial step towards truly personalized cardiovascular care across the lifespan. Improving cardiovascular care for women requires not only scientific and technological progress but also a broader cultural shift within the cardiovascular community. Disparities remain evident in the cardiology workforce, particularly in leadership positions, academic visibility, and opportunities for research collaboration. Importantly, these inequalities extend across cardiology subspecialties, with women underrepresented in most fields and particularly in interventional cardiology, where structural and occupational barriers persist.12,13 These disparities may influence research priorities and clinical perspectives, potentially affecting the development and dissemination of knowledge related to women’s cardiovascular health.14–16 Recent discussions during the meeting Women’s Voices in Cardiology (Figure 1), held in Istanbul, highlighted the importance of addressing sex differences in cardiovascular disease across the lifespan. This photograph captures participants attending the “Women’s Voices in Cardiology” event, held on 7 March 2026. The meeting brought together cardiologists across subspecialties to explore how sex-specific cardiovascular science can be better integrated into clinical practice and research. Particular attention was given to the need for closer collaboration between paediatric and adult cardiology in order to recognize early cardiovascular phenotypes and improve long-term cardiovascular care in women. An additional outcome was the proposal of a practical framework aimed at supporting equity within the cardiology profession itself. The ‘ABCD Code for Supporting Women in Cardiology’ (Figure 2) summarizes four key principles that may help foster more inclusive professional environments: (A) Acknowledge and amplify voices, ensuring that women’s contributions are recognized and credited in scientific discussions and academic activities. (B) Back opportunities, actively supporting women for research projects, leadership roles, conference presentations, and career development. (C) —Create fair systems, promoting transparent criteria for opportunities such as case allocation, academic advancement, and leadership positions. (D)—Disrupt bias, constructively addressing both explicit and implicit bias and encouraging training environments compatible with different life stages, including pregnancy and caregiving responsibilities. The “ABCD Code for Supporting Women in Cardiology” summarizes four key principles aimed at fostering more inclusive professional environments: (A) acknowledge and amplify voices, ensuring that women’s contributions are recognized and credited in scientific discussions and academic activities; (B) back opportunities, actively supporting women in research projects, leadership roles, conference presentations, and career development; (C) create fair systems, promoting transparent criteria for opportunities such as case allocation, academic advancement, and leadership positions; and (D) disrupt bias, constructively addressing both explicit and implicit bias while encouraging training environments compatible with different life stages, including pregnancy and caregiving responsibilities. This framework reflects the broader recognition that advancing cardiovascular science requires improving inclusivity within the scientific community. Increasing the visibility and representation of women in cardiology may broaden research perspectives, strengthen multidisciplinary collaboration, and contribute to improved cardiovascular care. Cardiovascular imaging is uniquely positioned to contribute to this change. By enabling precise characterization of sex-specific disease mechanisms and supporting earlier and more accurate diagnosis, imaging technologies play a crucial role in advancing female cardiovascular health. Addressing disparities in both imaging research and workforce representation, including within procedural subspecialties such as interventional cardiology, may further accelerate innovation and equity in cardiovascular care. Addressing these disparities requires greater inclusion of women in imaging research, sex-specific diagnostic thresholds, and increased awareness among clinicians. Integrating sex-specific cardiovascular science with a commitment to equity within the cardiology workforce may represent an important step towards more comprehensive and patient-centred cardiovascular care. Scientific innovation and inclusive professional cultures should be viewed as complementary elements in advancing cardiovascular medicine and reducing the burden of cardiovascular disease in women across the lifespan. Sara Moscatelli, MD, is a cardiologist with specialist expertise in paediatric cardiology and cardiovascular imaging. She has over 4 years of clinical experience in congenital heart disease and paediatric cardiomyopathies, with a particular focus on arrhythmogenic cardiomyopathies and their genetic basis. She has developed advanced skills in cardiovascular magnetic resonance (CMR), including tissue characterization and functional assessment during her work at the Royal Brompton Hospital in London. Dr Moscatelli is actively involved in research on desmosomal gene variants and arrhythmogenic cardiomyopathies, as part of her PhD programme. Her work focuses on genotype–phenotype correlations, early disease expression, and multimodality imaging markers in paediatric and young populations. She has experience in both clinical and translational research, including patient cohort analysis and basic laboratory techniques. She is a contributor to the ESC Council on Cardiovascular Genomics and is involved in international collaborative projects exploring inherited cardiovascular diseases. Alongside her clinical and research activities, she has a growing interest in artificial intelligence and its applications in cardiovascular imaging and data analysis. Dr Moscatelli is also actively engaged in promoting sex equity in cardiology. She has contributed to initiatives addressing sex-specific differences in cardiovascular disease and advocates for the integration of sex-aware approaches in cardiovascular imaging and clinical practice. She has participated in international discussions, including the Women’s Voices in Cardiology meeting, supporting greater collaboration between paediatric and adult cardiology and contributing to the development of frameworks aimed at fostering inclusivity and equity within the cardiology workforce. Dr Moscatelli is committed to advancing personalized cardiovascular care across the lifespan, with particular attention to early diagnosis, sex-specific differences, and the integration of imaging and genetics in paediatric populations. Sara Moscatelli (Conceptualization, Data curation, Validation, Visualization, Writing—original draft, Writing—review & editing [lead]), and Fatima Nihan Turhan Caglar (Writing—review & editing [supporting])