Sex differences in cardiovascular disease burden in Europe: insights and implications from the ESC Atlas

Background Despite growing recognition of sex disparities in cardiovascular health, contemporary analyses of sex-specific disease burden in European countries that could support the design of targeted prevention, risk assessment, and resource allocation strategies, remain limited. Aims As a companion to the 2025 ESC Atlas, we provide focused analyes of sex differences in cardiovascular disease (CVD) burden across ESC member countries Methods We used data from the 2023 Global Burden of Disease study. To examine risk factor exposure, we selected ten risk factors with established associations with CVD, and analysed age-standardised summary exposure values. To examine the CVD burden, we calculated age-standardised incidence rates per 100,000 person-years including all major CVD categories and maternal hypertensive disorders, and quantified each condition’s proportional contribution to total CVD burden. We performed all analyses by sex, at country, regional, and ESC-wide levels, and over time (1990–2023). Results In 2023, the ESC Region recorded 13.2 million incident CVD cases and approximately 4.02 million deaths, with women accounting for a slight majority of both cases (55%) and deaths (2.03 vs 1.99 million). This apparent parity in overall burden concealed marked sex differences in risk exposure, disease composition, and stages of epidemiological transition across countries. Behavioural risk factors, particularly tobacco and alcohol, were consistently 10–20 percentage points higher in men across most regions, while cardiometabolic risks such as high BMI and low physical activity were 5–15 percentage points higher in women, particularly in parts of North Africa, the Middle East, and Central Asia. In contrast, environmental and biological risks (e.g., air pollution, fasting glucose, cholesterol) showed smaller sex differences, generally within ±5 percentage points (Figure 1). The relative contribution of individual CVDs towards the overall burden also varied widely by sex and over time. Most notably, ischaemic heart disease and stroke accounted for 58% of incident CVD in men versus 38% in women, while peripheral artery disease and maternal hypertensive disorders together comprised 46% of CVD incidence in women. Over time, the proportional contribution of ischaemic heart disease declined in both sexes and was paralleled by a relative rise in non-ischaemic conditions, particularly among women (Figure 2). Conclusions Sex-specific differences in CVD burden highlight opportunities to strengthen prevention in the European region. In women, this includes broadening strategies beyond ischaemic heart disease to address peripheral arterial disease, atrial fibrillation, and maternal hypertensive disorders, alongside targeted reduction of cardiometabolic risk and regional inequalities; in men, priorities include intensifying atherosclerotic prevention and behavioural risk reduction, particularly in high-incidence regions.