Gender Differences in International Cardiology Guideline Authorship: A Comparison of the US, Canadian, and European Cardiology Guidelines From 2006 to 2020.

Background Women continue to be underrepresented in cardiology and even more so in leadership positions. We evaluated the trends and gender differences in the guideline writing groups of the American College of Cardiology/American Heart Association (ACC/AHA), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC) guidelines from 2006 to 2020. Methods and Results We extracted all guidelines authors from 2006 to 2020, assessed their gender from publicly available profiles, and compared differences based on subspecialties and specific societies. Stratified and trend analyses were performed using χ2 and average annual percentage change/average 5 year percentage change. A total of 80 ACC/AHA (1288 authors [28% women]), 64 CCS (988 authors [26% women]), and 59 ESC (1157 authors [16% women]) guidelines were analyzed. A significant increase in inclusion of women was seen in ACC/AHA (12.6% [2006] to 42.6% [2020]; average annual percentage change, 6.6% [2.3% to 11.1%]; P=0.005) and ESC (7.1% [2006] to 25.8% [2020]; average annual percentage change, 6.6% [0.2% to 13.5%]; P=0.04), but the trend remained similar in CCS (20.6% [2006] to 36.3% [2020]; average annual percentage change, -0.1% (-3.7% to 3.5%); P=0.94), guideline authors. More women were coauthors in the ACC/AHA and ESC guidelines when women were chairs of guidelines. There was a persistent disparity of women among guideline authors for general cardiology and all subspecialties, except for pediatric cardiology and heart failure guidelines. The appointment of women authors as a chair was significantly low in all societies (22.4% [ACC/AHA], 16.9% [CCS], and 7.2% [ESC]; P=0.008). Conclusions There is a significant disparity in the inclusion of women on all national guideline committees, in addition to serving as a chair of cardiology guidelines. Further advocacy is required to promote equity, diversity, and inclusion in our cardiology guidelines globally.

average 5‐year percentage change

average annual percentage change

American College of Cardiology/American Heart Association

Canadian Cardiovascular Society

European Society of Cardiology

women in cardiology

Clinical Perspective

What Is New?

There is a persistent underrepresentation of women authors in the US, European, and Canadian cardiology guidelines from 2006 to 2020 in authorship and as guideline chairs as well.

What Are the Clinical Implications?

Further continued advocacy efforts are needed to promote women in medicine and women in cardiology to ensure equity, diversity, and inclusion in cardiology guidelines globally.

Cardiovascular disease is the leading cause of mortality worldwide for both men and women, and guidelines are intended to provide evidence‐based guidance for the prevention and treatment. Globally, guidelines are created by content experts in the field to apply to specific populations. It has been postulated that diverse representation in guideline writing groups leads to diverse perspectives specific to race, ethnicity, and gender, thus enhancing broader relevance and applicability to the population at large. , Over the past decade, there has been a movement toward increased gender parity and inclusion at all levels of medicine, particularly in cardiology. , , Almost equal or more women enter medical school in the United States, Canada, and some European countries. , , However, as medical students further advance into their careers, the proportion of women progressively decreases in those selecting training in internal medicine residency, with even fewer selecting advanced training in cardiovascular disease. , , This has contributed to the limited growth in the number of women in cardiology (WIC); the inequity in the inclusion of women investigators in cardiology clinical trials and other leadership roles in cardiology ultimately impacts the ability for women to be seen as leaders and selected for serving on writing committees of national guidelines. ,

A recent study assessed the authorship of published articles in the leading cardiology journals over 20 years and reported an increase in the proportion of women senior authors from 5.1% in 1996 to 11.9% in 2016. Another study reported a persistent disparity with an increasing trend (22% in 2011 to 35% in 2020) in the inclusion of women authors in randomized clinical trials. Worldwide, the cardiology community has made efforts to bridge the gender gap, but the leadership gaps for WIC remain challenging to overcome. , , , , , Recent work by our group demonstrated gender inequities in writing group authorship in the American College of Cardiology/American Heart Association (ACC/AHA) and guidelines. It is unclear whether a similar trend is present in other countries. We assessed the trends of women’s inclusion on the cardiology guideline writing group on a global scale by comparing women authors of guideline writing group of ACC/AHA, the Canadian Cardiovascular Society (CCS), and the European Society of Cardiology (ESC).

Methods

We extracted the ACC/AHA, CCS, and ESC guidelines from the respective websites for 2006 to 2020. The older versions of guidelines were searched through bibliographic search. We excluded the compilation of guidelines to prevent duplications. The names of the chairs, co‐chairs, vice‐chairs, and authors of the guideline writing group were extracted. The gender of the authors was determined independently by the authors of the study by evaluating noun descriptions used in the biography page of their place of employment and social media. Gender was limited to binary as either man or woman. We were unable to categorize anyone as transgender, nonbinary, or gender nonconforming.

The ACC/AHA guidelines comprise both writing committees and task force, but the primary authors are members of the writing committees or guideline writing group and were the authors included in this analysis. The CCS has primary and secondary panel authors; the role of the primary panel is similar to the writing committee of the ACC/AHA, and the secondary panel is similar to that of task force members. Similarly, the ESC has task force and document reviewers, but the role of the task force is similar to the writing committee, and the document reviewers are similar to the task force of ACC/AHA. For our analysis, we included only writing committee members/guideline writing group or their international equivalent.

All of the extracted guidelines were divided into general cardiology and other subspecialties as interventional cardiology, electrophysiology, heart failure (HF), and pediatric cardiology under the guidance of senior authors (E.M. and M.G.). The detailed categorization is provided in Tables S1 through S6. All the chairs, co‐chairs, and vice‐chairs were considered as authors for overall analysis. All chairs, co‐chairs, and vice‐chairs were considered equal while analyzing chairs.

Categorical variables were presented as absolute numbers and percentages. Categorical variables across groups were compared using the χ2 test. We extracted the gender of all the authors; thus, we report absolute percentages and comparisons with other gender. The percentage trend of authorship over the years was reported using average annual percentage change and average 5‐year percentage change (A5PC), calculated using Joinpoint Regression Program 4.9.0.0. All analysis was performed using R version 4.0.3.

Because an author can be included in multiple guideline writing groups or for updated versions of the same guidelines, we also counted the frequency of individual authors within guidelines. When an author was included in multiple guidelines, the frequency of his/her repetition was counted, and he/she was considered a unique author. Similarly, we also counted unique guideline chairs. Institutional review board approval was not obtained as the data are publicly available.

Results

We extracted a total of 80 ACC/AHA, 64 CCS, and 59 ESC guidelines published between 2006 to 2020. The details of included guidelines, specialty/subspecialty classification, and extracted gender are provided in Tables S1 through S3. Among these guidelines published, a total of 1288 (360 [28.0%] women) authors from ACC/AHA, 988 (260 [26.3%] women) authors from CCS, and 1157 (191 [16.5%] women) authors from ESC guidelines were identified (P<0.0001), suggesting underrepresentation of women compared with men in all guidelines. Over 15 years, the trend in the inclusion of women authors in the ACC/AHA guidelines increased from 11 (12.6%) in 2006 to 63 (42.6%) in 2020 (average annual percentage change, 6.6% [2.3% to 11.1%]; P=0.005) compared with men. The inclusion of women authors remained similar in CCS guidelines, 7 (20.6%) in 2006 to 33 (36.3%) in 2020 (average annual percentage change, −0.1% [−3.7% to 3.5%]; P=0.94) compared with men. The trend in the inclusion of women authors in the ESC guideline increased from 1 (7.1%) in 2006 to 23 (25.8%) in 2020 (average annual percentage change, 6.6% [0.2% to 13.5%]; P=0.04; Figure 1A).

Figure 1

Trends in the inclusion of women authorship in American College of Cardiology/American Heart Association (ACC/AHA), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC) guidelines over 15 years, stratified on the basis of general cardiology/subspecialties and 5‐year trends.

A, Trends in the inclusion of women authors in ACC/AHA, CCS, and ESC guidelines from 2006 to 2020*. B, Overall inclusion of women authors in general cardiology and subspecialties guidelines. C, The 5‐year trends in inclusion of women authors in ACC/AHA, CCS, and ESC general cardiology guidelines. D, The 5‐year trends in inclusion of women authors in ACC/AHA, CCS, and ESC subspecialty guidelines. *CCS had no guidelines released in 2015.

Association of Gender of Chairs and Inclusion of Women

The appointment of women as chairs of the guideline writing group was infrequent (22.4% in ACC/AHA, 16.9% in CCS, and 7.2% in ESC guidelines). However, when women were chairs of the ACC/AHA guideline writing group, the inclusion of women coauthors was greater than when there were mixed gender chairs or only men as chairs (48% versus 30% versus 21%; P<0.0001). Similarly, for ESC guidelines, there were more women coauthors when women were chairs of guideline writing group compared with mixed‐gender chairs or only men as chairs (43% versus 34% versus 14%; P<0.0001). For the CCS guidelines, a similar but nonsignificant trend was seen in the inclusion of women based on the gender of the chairs (44% versus 34% versus 27%; P=0.1366).

Specialties/Subspecialties

The overall inclusion of women authors from 2006 to 2020 in general cardiology guideline writing group for the ACC/AHA versus CCS versus ESC guidelines was 260 (29.7%), 57 (19.3%), and 133 (17.0%) (P<0.0001), respectively, when compared with men. The inclusion of women authors in pediatric cardiology remained similar in all societies: ACC/AHA, 6 (40.0%); versus CCS, 24 (42.1%); versus ESC guidelines, 10 (27.8%) (P=0.37). The inclusion of women authors in HF guideline writing group differed by societies: ACC/AHA, 24 (41.4%); versus CCS, 118 (38.3%); versus ESC guidelines, 11 (15.3%) (P=0.0006). The inclusion of women authors in electrophysiology and interventional cardiology guideline writing group were the lowest of all subspecialties and were not significantly different among all 3 societies: electrophysiology: ACC/AHA, 34 (22.5%); versus CCS, 48 (21.3%); versus ESC, 23 (16.5%) (P=0.40); interventional cardiology: ACC/AHA, 36 (19.0%); versus CCS, 13 (12.6%); versus ESC, 14 (10.9%) (P=0.10; Figure 1B).

The 5‐Year Trends

General Cardiology

In 5‐year trends of general cardiology guideline writing group, there was a similar trend of women inclusion in ACC/AHA (A5PC, 42.5% [−80.7% to 954.5%]; P=0.266) and ESC guidelines (A5PC, 51.8% [−46.5% to 330.9%]; P=0.124). However, for CCS guidelines, there was a higher women inclusion in the first 5‐year compared with either of the ACC/AHA and ESC guidelines. Nevertheless, the inclusion of women in the CCS guidelines remained similar in the subsequent 5‐year intervals (A5PC, 4.1% [−80.7% to 460.4%]; P=0.812) (Figure 1C).

Cardiology Subspecialties

For the subspecialty guideline writing group, over 5‐year trends, there was a similar trend of women inclusion in the ACC/AHA guidelines (A5PC, 35.1% [−56.6% to 320.8%]; P=0.184). The women authors’ inclusion in the ESC guidelines was higher in the first 2006 to 2010, compared with 2011 to 2015, and then a higher inclusion in 2016 to 2020, and the trend remained similar (A5PC, 24.9% [−99.0% to 15 427.2%]; P=0.662). However, for CCS guidelines, the inclusion of women was higher in the first 5‐year interval than the ACC/AHA and ESC guidelines and remained relatively unchanged over the remaining time (A5PC, −5.1% [−11.8% to 2.0%]; P=0.068) (Figure 1D).

Unique Authors of Guidelines

The names and repetition of unique (single and repeated) authors are provided in Tables S4 through S6. For all ACC/AHA guidelines during the study period, of the 238 women authors, 31.9% were repeated, which was no different from the 556 men authors, where 32.9% were repeat authors (P=0.78). For all CCS guidelines, 34.5% were repeated women authors, similar to the 28.7% of men authors (P=0.20). Similarly, 33.6% were repeated women authors for the ESC guidelines, and 32.0% of men were repeat authors (P=0.74).

Overall, for all guideline writing group, the repetition of women authors was significantly higher than men authors (31.4% versus 20.0%; P<0.001; Table 1). The frequency of inclusion of unique men and women authors is shown in Table 2.

Table 1

Guideline Authors and Chairs of Guidelines: Single Authors Compared With Repeated Authors on Guidelines

Variable	Single guideline author		Repeated guideline authors
	Men	Women	Men	Women	P value
ACC/AHA	373 (67.1)	162 (68.1)	183 (32.9)	76 (31.9)	0.78
ACC/AHA chairs	59 (79.7)	19 (82.6)	15 (20.3)	4 (17.4)	0.76
CCS	256 (65.5)	102 (71.3)	135 (34.5)	41 (28.7)	0.20
CCS chairs	39 (78.0)	14 (100.0)	11 (22.0)	0	0.054
ESC	405 (68.0)	79 (66.4)	191 (32.0)	40 (33.6)	0.74
ESC chairs	51 (73.9)	5 (83.3)	18 (26.1)	1 (16.7)	0.61
All guideline authors	1034 (80.0)	343 (68.6)	509 (20.0)	157 (31.4)	<0.001
All guideline chairs	149 (77.2)	38 (88.4)	44 (22.8)	5 (11.6)	0.10

Data are given as number (percentage). ACC/AHA indicates American College of Cardiology/American Heart Association; CCS, Canadian Cardiovascular Society; and ESC, European Society of Cardiology.

Table 2

Frequency of Repetition of Unique Women and Men Authors and Chair in ACC/AHA, CCS, and ESC Guidelines

Frequency	20	13	11	10	9	7	6	5	4	3	2	1	Total
ACC/AHA: men	1	…		1	2	1	7	12	17	46	96	373	556
ACC/AHA: women	…	…	…	…	…	…	1	4	7	17	47	162	238
ACC/AHA chair: men	…	…	…	…	…	1	…	…	2	6	6	59	74
ACC/AHA chair: women	…	…	…	…	…	…	…	…	…	3	1	19	23
CCS: men	…	1	2	2	2	5	6	14	16	20	67	256	391
CCS: women	…	…	2	…	3	1	3	1	4	9	18	102	143
CCS chair: men	…	…	…	…	…	…	…	…	3	2	6	39	50
CCS chair: women	…	…	…	…	…	…	…	…	…	…	…	14	14
ESC: men	…	…	…	2	2	2	8	15	13	36	113	405	596
ESC: women	…	…	…	…	…	1	1	3	4	6	25	79	119
ESC chair: men	…	…	…	…	…	…	…	…	…	3	15	51	69
ESC chair: women	…	…	…	…	…	…	…	…	…	…	1	5	6

ACC/AHA indicates American College of Cardiology/American Heart Association; CCS, Canadian Cardiovascular Society; and ESC, European Society of Cardiology.

Unique Chairs of Guidelines

Overall, from 2006 to 2020, the appointment of women authors as chair, co‐chair, or vice‐chair was lower than men authors, with 30 (22.4%), 14 (16.9%), and 7 (7.2%) for ACC/AHA, CCS, and ESC guidelines (P=0.008), respectively.

For the ACC/AHA guidelines, of the 23 women who were guideline writing group chairs, 17.4% were repeat chairs, which was no different than repeat chairs for men (20.3%) (P=0.76). Nevertheless, for the CCS guidelines, all 14 women chaired guidelines only once, whereas of 50 men chairs, 22% were repeat chairs (P=0.054). For the ESC guidelines, 16.7% of women were repeat chairs, which was similar to men; of the 69 men chairs, 22.8% were repeat chairs (P=0.61). Overall, there was no statistical difference in the inclusion (single or repetition) of unique women versus men chairs in ACC/AHA and ESC guidelines (Table 1). There was no repetition of unique CCS chairs. The frequency of inclusion of unique women chairs as authors is shown in Table 2.

Discussion

In our analysis of ACC/AHA, CCS, and ESC guidelines published over the span of 15 years, we analyzed gender disparity in the inclusion of authorship. We report that there is (1) a noted gender disparity in the inclusion of women authors in the ACC/AHA, CCS, and ESC guideline writing group; (2) an increasing trend in the inclusion of women was seen in ACC/AHA and ESC guidelines, but it remained similar in CCS guidelines; (3) a higher inclusion of women authors with women as chair in the ACC/AHA and ESC guidelines; (4) the inclusion of women authors was higher in HF and pediatric cardiology guideline writing group, but lower in electrophysiology and interventional cardiology; (5) over 5‐year intervals, there was a progressive increase in the inclusion of women authors in ACC/AHA and ESC general cardiology guideline writing group, and it remained similar in the CCS guideline writing group; and (6) women authors (but not women chairs) had a higher tendency of repetition compared with men.

To the best of our knowledge, this is the first study assessing the global representation or inclusion of women in the national guideline writing group; our study provides a broader perspective and changes over the past 15 years in the WIC and their inclusion in the national leadership. There is an increasing trend toward women’s inclusion in ACC/AHA and ESC guideline writing groups; however, it has remained similar in the CCS guideline writing group. Despite an increasing trend, a persistent gender disparity has existed over the years, which could be attributed to overall less WIC. In 1995, the ACC WIC became a section within the ACC and undertook multiple concerted efforts by setting up statewide WIC chapters to motivate medical students and residents to pursue a career in cardiology and promote leadership. The ESC, under the leadership of Dr Barbara Casadei, launched the Women in ESC initiative and Women Transforming Leadership Program in 2015 to advance women cardiologists as leaders. , The CCS started the 3G (geography, gender, and generation) principle in 2020 to increase the inclusion of WIC. The CCS guideline writing group had higher women inclusion 15 years ago; however, the inclusion remained similar over the years. In recent years, the increase in the inclusion of women in the ACC/AHA guideline writing group is likely a result of the sustained and active efforts by ACC/AHA. The ESC guideline writing group had the lowest inclusion of women to start with and has improved with time but still has the least percentage of women included in their guidelines of the 3 societies. Continued efforts with these initiatives may break the barriers and promote gender parity.

The representation of women decreases progressively from medical school to internal medicine residency and drops further toward cardiology fellowship, known as “residency to fellowship cliff.” It drops even further from fellowship to subspecialty fellowship, known as “second cliff.” It drops even more toward the inclusion or appointment of women at leadership positions, known as “leaky pipeline.” , Although there is almost gender parity in internal medicine residency training, there remains a significant lack of women cardiology fellowship trainees. A survey of 1123 internal medicine residents from the US residency programs reported work‐life balance, need for mentorship, and positive role model as the most substantial factor for choosing cardiology. Reassuringly, there is an increasing trend toward increased women cardiology trainees in the US fellowship program over the past decade (15.9% in 2008 to 21.4% in 2018). An interesting system‐based quality initiative at Duke Cardiovascular Research Institute, aiming to promote women and underrepresented ethnic group representation in cardiology fellowship, resulted in improvement from a mean of 23.2% to 54.2% of women within 2 years. Increasing WIC can lead to increased leadership roles, ultimately bridging the gap in guideline authorships as well (Figure 2). Similar system‐based initiatives at multiple levels can break the barriers and promote WIC.

Figure 2

Women and men authorship in guidelines, barriers to low women in cardiology (WIC), and possible solutions to promote WIC.

 

The task force selects the writing committee or guideline writing group members after selecting the chair, co‐chair, or vice‐chair. Although the chair does not select guideline writing group, the statistical relation between the women or mixed‐gender chair association with higher inclusion of women and vice versa was observed in our study, suggesting inherent biases in selecting chairs and members. Women authors tend to be repeat authors; this can be attributed to fewer WIC and representation in leadership roles. However, it was also demonstrated that some men authors are included as authors repeatedly, with a few in >5 guidelines. Limiting the repeat inclusion of authors on the guidelines can provide an opportunity for others to participate in the guideline writing group. Interestingly, men authors also have a greater tendency to be repeat chairs. When women were chairs of guidelines, there was a significant inclusion of women as authors. Thus, creating gender equity in chairs’ leadership roles can also help bridge the gap, leading to more women authors on the guideline writing group (Figure 2).

Typically, a “guideline writing group should include knowledgeable, multispecialty/disciplinary development individuals.” The expertise is determined by clinical experience and research expertise on the topic. Traditionally, guideline authors have been chosen and not elected, and thus, the selection process lacks transparency. In cardiology, our evidenced‐based guidelines are considered the foundation of our practice, yet the process of selecting the guideline authors and their impact on the quality of guidelines and their impact on patient‐centered outcomes have not been established. A study assessing gender differences in authorship among published articles in 6 leading cardiology journals revealed an increase in women first authors from 11.3% in 1996 to 20.8% in 2016, yet a significant disparity exists. A study assessing gender differences in first authors in published randomized clinical trials demonstrated an increase in women authors despite a persistent gender disparity over the past decade. Another study reported a significant gender gap in Canadian Institute of Health and Research grant funding, attributing this to a less favorable assessment of women as principal investigators. Focused attempts from the grant agencies and creating objective criteria for assessing the quality of grants for funding after blinding the name, gender, and institution of authors could remove these inherent biases. Similar blinded and objective assessments can be helpful in academic promotions and appointment of the leadership roles, such as guideline authorship and chairs (Figure 2).

Guidelines are critical for the evidence‐based delivery of patient care, and guideline authors should ideally reflect the patient population we serve. It is essential to have diverse gender, race, and ethnicity representation in the guideline writing group and leadership to improve the applicability of guidelines on the diverse patient populations we care for. A recent report from Canada assessed gender disparities in the cardiovascular community and reported the persistent underrepresentation of women as authors on Canadian guideline writing group, which is consistent with our findings. ,

A study by our group assessing gender disparity in the authorship of the ACC/AHA from 2005 to 2019 revealed a trend toward greater inclusion of women as the author of national guidelines during the study period; the inclusion of women was low in general cardiology, interventional cardiology, and electrophysiology. The percentage of women cardiology trainees has been slowly increasing over the past decade. However, women pursuing a further specialization in electrophysiology and interventional cardiology remain remarkably low. This is also evident from the comparatively lower percentage of women authors’ inclusion in electrophysiology and interventional cardiology guidelines. The results of our study are consistent with a prior editorial comparing women’s authorship in multiple ACC/AHA guidelines. The culture of interventional cardiology and women are more likely to be influenced away because of lack of job flexibility, physically demanding job, radiation during pregnancy, lack of women role models, and gender discrimination, as per a survey of cardiology fellows in training in the United States, which pans out to lack of WIC in the interventional cardiology guidelines. Similar factors have been reported worldwide in multiple studies, making women shy away from interventional cardiology. , , , , Given the nature of procedure‐oriented training and exposure to radiation, similar reasons could be attributed to the lack of women trainees shying away from electrophysiology as well.

Our study reveals a higher percentage of women authors in the HF and pediatric cardiology guideline writing group. The higher percentage in pediatric cardiology could be attributed to a higher proportion of women in pediatrics residency. There is a higher percentage of HF women trainees than other subspecialty fellowships. HF also has more women role models and support for women cardiologists, promoting trainees to pursue HF as a career choice. , The HF is considered a women‐lead specialty ; perhaps the reason for a higher proportion of WIC pursuing HF as a career, leading to higher inclusion of women in HF guidelines than others. Several initiatives have been taken by the Society for Coronary Angiography and Interventions, European Association of Percutaneous Cardiovascular Interventions, CCS, Women in Electrophysiology, Women as One, and ACC/AHA WIC section to attract women toward a career in cardiology. , , , , , ,

To summarize, there has been slow growth in WIC and their inclusion in the guideline writing group in ACC and ESC guidelines, and it has remained similar in the CCS guidelines over the past decade. This is because of the fewer WIC and the leadership roles. A dedicated mentorship program advocating and promoting WIC from early in the career for research and leadership may promote the visibility of WIC. This will lead to more available women mentors in cardiology, which can amplify medical students’ interest in pursuing cardiology, increasing WIC. Implementation of transparent and objective criteria for appointment as authors and chair position can also prevent implicit bias and promote gender parity. Increasing gender parity in WIC and authorship will lead to diverse representation and the development of balanced guidelines that impact patient outcomes (Figure 2).

The strengths of our study include its novelty in assessing the global perspective of women’s authorship and inclusion in national guidelines, the trend over the years, specialty and subspecialty trends, unique authorship and chair discernment, and the effect of gender of the chair on the inclusion of women authors in the guidelines. We included all published guidelines over the past 15 years, providing a broader overview and change in the trends over time. Nevertheless, our study contains certain limitations as well. The gender of the authors was determined by the available biography at the place of employment website and social media; there is room for error in identifying gender. However, the gender was identified independently by 2 authors to minimize the error. In addition, gender is not binary, yet we were limited to binary determination for our study.

In conclusion, there has been a consistent gender disparity among the ACC/AHA, CCS, and ESC guidelines over the past 15 years regarding the inclusion of women authors. There is a trend toward improved inclusion in ACC/AHA and ESC guidelines; however, it has remained similar in CCS guidelines. HF and pediatric cardiology guidelines have comparatively higher inclusion than electrophysiology and interventional cardiology guidelines. The gender disparity is even higher in chair and vice‐chair positions. Further active efforts are required globally to promote women’s inclusion in leadership, ultimately leading to the authorship of the guidelines and closing gender disparity.

Sources of Funding

None.

Disclosures

None.

Tables S1–S6

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