Cardiovascular disease outcomes: does physician’s sex matter?

The recognition of sex-based differences in cardiovascular outcomes is not new. Landmark contributions, from Dr Bernadine Healy’s ‘Yentl syndrome’,1 and the Women’s Ischemia Syndrome Evaluation (WISE) study,2 to Dr Nanette Wenger’s, ‘bikini approach’ to women’s health,3 and work on non-obstructive coronary disease by Drs Raffaele Bugiardini and C. Noel Bairey Merz4 exposed the systematic underdiagnosis and misclassification of women’s cardiovascular risk. These insights established sex-specific cardiology as a clinical and research priority, prompting calls for tailored strategies and adequately powered trials. Despite decades of advances, disparities persist. Women remain underdiagnosed, undertreated, and underrepresented in trials.5,6 Biological, socio-economic, and structural factors continue to produce worse outcomes for women, compelling the field to explore drivers beyond patient-level sex differences.5,6 Cardiology remains one of the least diverse medical specialties. In Europe, women represent only 38% of cardiologists, with wide variation, dropping to 15.5% in the UK, and even lower representation in leadership and interventional subspecialties.7 This lack of diversity reinforces bias and restricts the professional perspectives that shape clinical practice and research priorities. Diversity is a clinical imperative; it enriches mentorship and ensures sensitivity to sex, culture, and ethnicity, ultimately correlating with improved patient outcomes. Evidence suggests who delivers care matters as much as how care is delivered.8,9 Against this background, a key question emerges: could a physician’s sex influence cardiovascular outcomes? The 2025 ESC Congress Fireside Chat, ‘Cardiovascular Disease Outcomes: Does Physician’s Sex Matter?’, hosted by Dr Edina Cenko and Prof. Elena Osto and featuring Prof. Roxana Mehran, highlighted how diversity and communication intersect to drive clinical performance (Figure 1A). Advancing cardiovascular care through communication and diversity. (A) Fireside Chat session at ESC Congress 2025, Madrid. Featuring (left to right): Dr Edina Cenko, Chairperson of the ESC Working Group on Coronary Pathophysiology and Microcirculation; Prof. Roxana Mehran, recipient of the ESC 2025 Gold Medal and founder of Women as One; and Prof. Elena Osto, Chairperson of the ESC Working Group on Atherosclerosis and Vascular Biology. (B) Conceptual framework showing potential pathways through which physician sex may influence cardiovascular outcomes via interpersonal dynamics, practice patterns, and institutional factors. (C) Conceptual summary showing how diversity can drive improvements in cardiovascular care through advances in education, research, clinical culture, and policy. Any observed influence of physician sex on outcomes, as outlined in B, should not be interpreted as implying that one sex provides inherently superior care. Rather, these patterns underscore how awareness of bias and greater system diversity can refine individual clinical practice and improve care for all patients. The goal is not to match patients and physicians by demographic characteristics, but to understand and implement the communication practices, institutional cultures, and system-level factors associated with better outcomes The concept of patient–physician sex concordance has gained attention.8,9 The assumption is that outcomes may differ when physicians and patients share the same sex. Studies suggest that the physician–patient relationship, shaped by empathy, communication, and implicit bias, may influence diagnostic and therapeutic decisions and outcomes.8,9 In cardiovascular care, these dynamics appear to translate into measurable effects. Several studies have demonstrated better short-term outcomes among patients treated by female physicians.8,9 Notably, in acute myocardial infarction, the higher mortality observed among female patients treated by male physicians was attenuated in emergency departments with greater female representation: for every 5% increase in female physicians, female patient survival improved by 0.4%, suggesting that diversity itself may improve performance and outcomes.8 A systematic review by Harik et al.9 found sex concordance was associated with greater adherence to evidence-based therapies and improved survival, especially among women with acute coronary syndromes. Yet heterogeneity and residual confounding limit causal inference. As the authors concluded, ‘the sex of the physician appears to matter, but not in isolation, it acts through a network of sociocultural and behavioural factors shaping clinical decisions and patient trust’. Several mechanisms may explain why physician sex influences cardiovascular outcomes (Figure 1B).8,9 First, communication and trust: female physicians often adopt patient-centred communication, eliciting concerns and encouraging symptom reporting. In cardiovascular care, where symptoms in women are often ignored, such engagement can reduce diagnostic delay. Patients also report greater trust in same-sex physicians, improving adherence. Second, practice patterns and patient mix: female physicians more frequently serve disadvantaged communities, work effectively within multidisciplinary teams, and adopt more cautious guideline-concordant clinical strategies.10 Third, bias and lived experience: while all clinicians can underestimate cardiovascular risk in women, female physicians, having experienced bias themselves, may be more alert to these pitfalls. Finally, institutional effects: hospitals with more women in clinical and leadership roles show better communication, adherence to guidelines, and patient safety.8 Distinguishing sex (biological differences) from gender (sociocultural roles, identities, and behaviours) is essential. Much of the literature conflates the two, but future research should consider the broader construct of gender diversity. What appears as a ‘sex effect’ may instead reflect gendered differences in communication, leadership, or institutional support. As cardiovascular medicine embraces precision health, understanding how gender dynamics influence clinical encounters will become as critical as molecular or imaging biomarkers. Focusing solely on binary male–female distinctions risks oversimplifying a complex social construct. Current evidence is limited by its observational nature and lack of intersectional data. Cohorts are male dominated, reflecting the small number of female physicians. Confounding factors such as physician age, experience, and case complexity are difficult to disentangle, and few studies examine the long-term effects of sex concordance on chronic disease management or secondary prevention. The underrepresentation of women of colour and other minorities in cardiology further complicates sex-concordance research. Because sex interacts with race and ethnicity, matching patients by sex alone oversimplifies the barriers faced by minority populations. Future research must integrate quantitative outcomes with qualitative insights from both patients and physicians. Understanding how sex, race, and ethnicity dynamics operate within multidisciplinary teams may finally prove more informative than focusing on physician sex alone. The central question is no longer whether the physician’s sex matters, but how awareness of these differences can improve outcomes for all patients. Translating this awareness into action requires concrete steps (Figure 1C). Systematic collection of physician sex, gender, race, and ethnicity using standardized, validated measures would enable stronger causal inference about how clinician demographics interact with institutional factors, team composition, and patient characteristics to influence cardiovascular outcomes. Broadening leadership opportunities for women and underrepresented racial and ethnic groups can help diversify the profession. Incorporating inclusive communication training and programmes on unconscious bias into medical education can help recognize inequities. Ensuring balanced representation in clinical teams and decision-making bodies, together with recruiting diverse trial populations and investigator groups, will further strengthen the quality and relevance of cardiovascular research.5,6,8,9,11 This evidence compels us to reflect on our clinical encounters. Every decision, from symptom interpretation to risk communication, is filtered through a human lens that we must acknowledge to achieve truly equitable care. Ultimately, these disparities reflect structural inequities within healthcare systems and society. Cardiovascular professionals must remain aware of how their actions can perpetuate these inequities and consciously consider sex, gender, race, and ethnicity when personalizing patient treatment. R.M. reports grants from Abbott, Alleviant Medical, Chiesi, Concept Medical, Cordis, CPC Clinical Research, Daiichi Sankyo, Duke, Faraday Pharmaceuticals, Idorsia Pharmaceuticals, Janssen, MedAlliance, Medtronic, NewAmsterdam Pharma, Novartis, Novo Nordisk Inc., Population Health Research Institute (PHRI), Protembis GmbH, Radcliffe, RM Global Bioaccess Fund Management, Sanofi US Services, Inc. all unrelated to this work. The other authors (E.C., E.O.) have nothing to disclose.