Bridging the Gender Gap: The Urgent Need for Cardiovascular Data on Women

Cardiovascular disease (CVD) remains the leading cause of mortality among women globally, accounting for over 204 deaths/100,000 women annually.^[1] Despite the significant cardiovascular burden in women, there are no large-scale worldwide or regional data available in the literature, mainly due to misdiagnosis, non-adherence to guideline-directed therapies, limited inclusion of women in cardiovascular research, lack of sex-specific clinical guidelines, and systemic healthcare inequities.^[2] This is a global problem, especially in underdeveloped or developing countries.

Women demonstrate distinct cardiovascular pathophysiology, clinical presentation, and response to therapy. Beyond traditional risk factors, female-specific and female-predominant conditions including hypertensive disorders of pregnancy, premature menopause, polycystic ovary syndrome, autoimmune diseases, and breast cancer therapies significantly influence cardiovascular risk profiles. Sociodemographic determinants such as low educational attainment, economic disadvantage, health illiteracy, and restricted access to care further exacerbate these risks.^[3-5]

We appreciate the authors who published their data on CVD in Women in Iraq – The Unseen Epidemic in the present issue of this journal despite financial constraints.^[6]

Iraq has experienced decades of war, political instability, and disruption of its healthcare system. Today, the country faces a growing burden of non-communicable diseases such as CVD, cancer, and diabetes. These diseases now account for 62% of all deaths in Iraq. Among them, CVD alone causes nearly 30% of all deaths. Alarmingly, this trend is rising, especially among younger people.^[7]

Several factors are driving the CVD epidemic in Iraq. These factors are also seen almost in other regions, such as changes in diet, reduced physical activity and increased stress, and poor nutrition. At the same time, women in Iraq face additional barriers. Cultural norms, gender inequality, and limited access to healthcare prevent many women from receiving timely diagnosis or treatment for heart disease.^[8]

There is very little sex-specific global data on CVD more so from Iraq. This makes it difficult to understand the true burden of disease among women. The problem is not limited to Iraq. Across the Middle East and North Africa region, diseases like rheumatic heart disease are still common, especially in women.^[9,10]

The Iraqi Registry of CVDs in Women (IROCW) Women’s Heart Registry:

The pilot phase of the IROCW, led by Ali Farhan et al.,^[6] is a compelling example of pragmatic research innovation in a low-resource and conflict-affected context. This multicenter, prospective registry conducted across seven cardiac centers in Iraq was designed to evaluate the feasibility of establishing a sex-specific cardiovascular database in the absence of external funding and electronic health infrastructure. The findings from this 7-week pilot study not only confirm the viability of such an approach but also offer important insights into the cardiovascular health profile of Iraqi women.

A total of 150 women were enrolled, with a mean age of 60 years. The majority (89.3%) lived in urban areas, but most participants were socioeconomically disadvantaged. Nearly 60% reported a total family income below $500 USD per month, and educational attainment was low, 47.3% were illiterate, and 34.7% had only completed primary school. These findings highlight the broader social determinants of cardiovascular risk in this population, particularly the impact of low health literacy and restricted access to care.

Hypertension was the most common cardiovascular risk factor, followed by diabetes. Sex-specific contributors such as natural and surgical menopause and gestational hypertension were also frequently reported. The disease spectrum included ischemic heart disease (n = 77), heart failure (n = 24), valvular heart disease (n = 25), arrhythmias (n = 21), and acute coronary syndromes (n = 22), with diagnostic overlap observed in several cases. Despite the clinical complexity, echocardiography was performed in only 26% of patients, reflecting diagnostic limitations in daily practice.

Pharmacologic therapy largely followed standard guidelines, with high rates of aspirin (85.8%), statin (87.9%), beta-blocker (71.1%), angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) (62.8%), and P2Y12 inhibitor (60.4%) use. However, only 7.2% of eligible patients received mineralocorticoid receptor antagonists, revealing a significant treatment gap, especially in heart failure management. While dietary advice was provided at discharge in 96.6% of cases, essential secondary prevention strategies – such as smoking cessation counseling and referral for cardiac rehabilitation – were largely absent.

Importantly, the pilot achieved a 1-month follow-up rate of 78%, a notable success in a setting without electronic medical records. Loss to follow-up was mainly due to limited digital literacy and poor communication systems. To improve retention, the second phase of the registry includes collecting contact information for both the patient and a family member.

Beyond feasibility, the IROCW initiative contributed meaningfully to research capacity building in Iraq. It engaged junior doctors and medical students, especially women, in clinical research and data collection, helping address the gender gap in both research participation and cardiovascular care delivery.

Nevertheless, several limitations must be acknowledged. The registry involved only seven centers, limiting national representation. Data collection was conducted through Google Forms, which, while practical, lacks the robustness of standard clinical trial platforms. Certain cardiovascular conditions, such as myocarditis, pericardial disease, and peripheral artery disease, were not included. In addition, follow-up data were incomplete for a significant minority of participants.

Despite these constraints, the IROCW pilot represents a significant step toward building a sex-specific cardiovascular evidence base in Iraq. It lays a critical foundation for future large-scale efforts and serves as a model for other low- and middle-income countries seeking to address the persistent gaps in women’s cardiovascular health data.

We should seek the support of government bodies and gender-specific organizations to promote more structured research in the field of CVD in women.