The Importance of Gender to Understand Sex Differences in Cardiovascular Disease

Abstract

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. There is robust evidence of heterogeneity in underlying mechanism, manifestation, prognosis, and response to treatment of CVD between male and female patients. Gender, which refers to the socially constructed roles, behaviours, expressions, and identities of individuals, is an important determinant of CV health, and its consideration might help in attaining a broader understanding of the observed sex differences in CVD. Established risk factors such as hypertension, dyslipidemia, diabetes mellitus, obesity, and smoking R ESUM ELes maladies cardiovasculaires (MCV) sont la principale cause de morbidit e et de mortalit e à l' echelle mondiale. Des donn ees robustes t emoignent de l'h et erog en eit e entre hommes et femmes concernant le m ecanisme sous-jacent, la manifestation, le pronostic et la r eponse au traitement de MCV. Le genre, qui renvoie à une construction sociale des rôles, des comportements, de l'expression et de l'identit e individuelle, est un d eterminant important de la sant e cardiovasculaire (CV), et sa prise en compte pourrait aider à mieux comprendre les diff erences observ ees entre les sexes à l' egard des MCV. Il est bienCardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. 1 Despite growing awareness of the role of sex and gender in the management of CVD, female patients continue to experience delays in diagnosis and treatment, 2,3 are referred to and participate less in cardiac rehabilitation, 4 are not sufficiently represented in clinical trials, 5 and as a consequence may often suffer worse outcomes.In the medical literature, the terms "sex" and "gender" are sometimes interchangeably used, generating confusion. Sex refers to the biological characteristics of an individual as determined by chromosomal complement and sex hormones. The impact of these biological factors on CV risk are well established. [6][7][8][9] For example, low levels of estrogen in younger females are associated with an increased risk of CVD, 10,11 and declining estrogen levels after menopause, in addition to advancing age, are associated with unfavourable lipid profiles, 12 blood pressure (BP) elevation, and increased CV risk. 13 Moreover, pregnancy-related complications, such as gestational diabetes and preeclampsia, may alter this risk, as well as endocrine disorders, such as polycystic ovarian syndrome, which may promote CVD. 14,15 Beyond sex, gender derives from the social, cultural, and behavioural factors that may modulate health. 16,17 Gender is a multidimensional concept that incorporates identity (ie, an inner sense of masculinity, femininity, or gender nonconformity), role (ie, societal and environmental expectations), relationships (ie, interpersonal interactions and dynamics), and institutionalised gender (ie, distribution of power in political, educational, social institutions in society). 18 Gender may significantly influence health-related behaviours and interact with CV risk factors....

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Cardiac Rehabilitation: Under-Utilized Globally

“…Relatedly, women more often report pain or fatigue from exercise (58). They also frequently have transportation barriers, which may be related to their often lower socioeconomic status due to the gender pay gap, and being widowed for example (59). And finally, as women are more often informal caregivers than men, and marry older partners who are hence more prone to chronic illness, women often have family responsibilities they put before their own health care such as participating in CR.…”

Integrating sex and gender in studies of cardiac resynchronization therapy: a systematic review

“…The reasons remain unclear due to the underrepresentation of women in trials, 2 but they are likely to be multi‐faceted. Evidence shows that they may be due to differences in physiology, disease presentation, and gender‐related behaviours 1,3 . These uncertainties could be elucidated by improved reporting and integration of sex and gender in studies.…”

“…Evidence shows that they may be due to differences in physiology, disease presentation, and gender‐related behaviours. 1 , 3 These uncertainties could be elucidated by improved reporting and integration of sex and gender in studies.…”