Cardiovascular disease (CVD) remains a major cause of illness and death among Australian women, yet differences in presentation, diagnosis and treatment can mean women do not always receive the same care as men.
Historically, cardiovascular research and clinical practice have often treated men as the default. But there are important differences between men and women in cardiovascular risk factors, disease mechanisms, presentation and outcomes.
Women are less likely than men to report typical chest pain during an acute coronary syndrome (ACS), and are more likely to report symptoms such as dyspnoea, nausea and fatigue. These differences can complicate diagnosis and contribute to delays in treatment.¹
Tory Warner, Lead Cardiology Pharmacist at Alfred Health in Melbourne, says awareness of these differences has improved, but translating that knowledge into practice remains a challenge.
‘In my experience, there certainly has been some increased awareness of these issues,’ Ms Warner says. ‘However, this doesn’t necessarily always equal changed practice and women’s symptoms are often still interpreted in a male-centric framework.’
Australian research has also identified sex disparities in the management of ACS. A Victorian study of almost 29,000 patients found women were less likely than men to undergo coronary angiography, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).² More recent Victorian data also found women with ACS were less likely to receive several elements of guideline-directed care, including angiography.³
‘We have evidence in Australia that there are sex disparities beyond diagnosis,’ Ms Warner says. ‘Women with acute coronary syndrome are less likely than men to undergo angiography or percutaneous coronary intervention. And women with established CVD are less likely than men to receive recommended first-line therapies.’
The Heart Foundation’s ACS Guideline also notes that women are less likely than men to be prescribed statins following ACS.⁴
Ms Warner says both women and men can experience symptoms such as breathlessness, fatigue, nausea or dizziness, but clinicians need to avoid allowing these symptoms to be prematurely attributed to another condition.
‘Without adequate consideration of CVD, women’s symptoms may be more likely to be interpreted as anxiety or related to menopause,’ she says.
‘It is very important that gender bias is addressed. One way is to standardise care so opportunities for unconscious bias are reduced.’
Ms Warner points to a pharmacist-led intervention following ACS as one example of how standardisation can support more consistent secondary prevention.
‘Credentialed pharmacists systematically review patients against a standardised protocol looking at antiplatelet therapy, lipid-lowering therapy, blood pressure management, diabetes management, smoking cessation and vaccination,’ she says.
‘Standardisation and embedding treatment decisions into clear protocols, checklists and clinical pathways can reduce subjective perceptions of who is more likely to benefit.’
More education needed
For Ms Warner, standardised care pathways need to be accompanied by better education across health professions.
Medical, nursing and pharmacy education should explicitly address sex differences in CVD, including presentation, risk factors, diagnosis, treatment and outcomes, she says.
The issue extends beyond clinical diagnosis and treatment. A Victorian study of more than 32,000 out-of-hospital cardiac arrests found women were less likely to receive bystander defibrillation, despite no significant adjusted sex difference in the provision of bystander CPR. The disparity in defibrillation increased over the study period.⁵
Ms Warner says this highlights the need for practical training.
‘If people are uncomfortable exposing a woman’s chest, or don’t know how to position defibrillator pads when breasts are present, that is a training problem – not a reason to delay lifesaving treatment,’ she says.
‘CPR training should routinely include female-bodied mannequins and explicitly address the practical and social barriers
to providing CPR and defibrillation to women. It is difficult to expect people to respond confidently to a situation they have never encountered in training.’
For Ms Warner, the broader challenge is moving beyond recognising that a gender gap exists.
‘The key step in moving forward is to move from “we know there is a gender gap” to building gender-responsive care into healthcare systems,’ she says.
Bias at the bedside
Karl Winckel, Senior Hospital Pharmacist at Princess Alexandra Hospital in Brisbane, says the way patients are counselled about symptoms can also reinforce a male-centric model of cardiovascular care.
‘We often counsel male and female patients to watch for signs of chest pain after a heart attack,’ Mr Winckel says. ‘I inform them that this is ischaemic pain and that they need to use their glyceryl trinitrate (GTN) spray.’
But he says counselling needs to reflect the symptoms that triggered the hospital presentation.
‘Often women are less likely to experience this type of typical ischaemic chest pain and should be counselled considering the symptoms which brought them into hospital, for example shortness of breath and feeling “washed out”.’
The risk, he says, is that non-specific symptoms are overlooked because patients and health professionals are primed to look for the textbook presentation.
‘Because these non-specific symptoms may or may not reflect ischaemic pain, it’s often ignored – and they can be counselled instead to be alert for typical chest pain, which is more relevant to men.’
Mr Winckel says assumptions about cardiovascular risk can also affect treatment.
‘Women are also often not treated as aggressively as men because there is a bias that they are lower risk. While women who haven’t had a cardiovascular event are at low risk, those who have had a CV event are at very high risk of another one.’
Evidence supports the broader concern about differences in treatment. Studies have found women with ACS are less likely than men to receive some evidence-based medicines and invasive interventions.⁶
Mr Winckel says assumptions can work in the opposite direction too.
‘Another gender bias which exists includes the widespread view that women always adhere to medicines and other treatments. It’s not always true, and attention needs to be paid to the possibility that female patients may not follow their treatment plan.’
He also says patients may be reluctant to challenge a diagnosis or treatment plan.
‘I generally find most patients, male or female, say nothing if misdiagnosed, but perhaps it’s more common in women. They generally don’t want to risk damaging the relationship with their consultant by complaining or even questioning the diagnosis.’
Mr Winckel says addressing these issues requires changes at both an individual and system level.
‘As an educator, I know short-term solutions all involve education – ensuring health care workers, including pharmacists, are trained to identify and consider these issues.’
That training could occur across undergraduate and postgraduate education, as well as through continuing professional development, he says.
Longer-term change could include greater representation of women in senior cardiovascular roles and clearer guidance that explicitly recognises sex differences in cardiovascular care.
‘Having guidelines specify treatment pathways for men and women – even if they follow the same pathway – flags to people that men and women may need different courses of action,’ Mr Winckel says.
References
- National Heart Foundation of Australia; Cardiac Society of Australia and New Zealand. Comprehensive Australian clinical guideline for diagnosing and managing acute coronary syndromes 2025. Heart Lung Circ 2025;34(Suppl 2):S1–75.
- Worrall-Carter L, McEvedy S, Wilson A, Rahman MA. Gender differences in presentation, coronary intervention, and outcomes of 28,985 acute coronary syndrome patients in Victoria, Australia. Womens Health Issues. 2016;26(1):14-20.
- Dawson LP, Nehme E, Nehme Z, et al. Sex differences in epidemiology, care, and outcomes in patients with acute chest pain. J Am Coll Cardiol 2023;81(10):933–45.
- van Oosterhout REM, de Boer AR, Maas AHEM, et al. Sex differences in symptom presentation in acute coronary syndromes: a systematic review and meta-analysis. J Am Heart Assoc 2020;9(9):e014733.
- Paratz ED, Nehme E, Heriot N, et al. Sex disparities in bystander defibrillation for out-of-hospital cardiac arrest. Resusc Plus 2024;17:100532.
- Garcia M, Mulvagh SL, Bairey Merz CN, et al. Cardiovascular disease in women. Circ Res 2016;118(8):1273–93.
- Geraghty L, Figtree GA, Schutte AE, et al. Cardiovascular disease in women: from pathophysiology to novel and emerging risk factors. Heart Lung Circ 2021;30(1):9–17.
- Heart Foundation. Cardiovascular disease risk factors and heart attack warning signs in women. At: www.heartfoundation.org.au
- Healthdirect Australia. Heart attack. 2024. At: www.healthdirect.gov.au/heart-attack
- Heart Foundation. Heart attack. At: www.heartfoundation.org.au/your-heart/heart-attack
- Healthdirect Australia. Heart attack symptoms: males vs females. 2024. At: www.healthdirect.gov.au/heart-attack-symptoms-males-vs-females
